AccountId: 011433970860
ContactId: 4049a651-579e-42c5-b370-a44b57a54f42
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 895559 ms
Total Talk Time (AGENT): 218455 ms
Total Talk Time (CUSTOMER): 207147 ms
Interruptions: 0
Overall Sentiment: AGENT=0, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/09/4049a651-579e-42c5-b370-a44b57a54f42_20250509T17:01_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh, hi, this is [PII] calling from provider's office to check on a claim.
[AGENT][NEUTRAL] OK [PII], I can help you with the claim status, ma'am. May I please get your callback number?
[CUSTOMER][NEUTRAL] Yeah, it is [PII].
[AGENT][NEUTRAL] Thank you. And then what's the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Yeah, the policy number is 02135063.
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, I look that up.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And then what is the data service and the charge amount?
[CUSTOMER][NEUTRAL] Yeah, data service is uh 317 [PII] with the total charge amount of $301 even.
[AGENT][NEUTRAL] OK, and what's the charges after the primary insurance paid their part?
[CUSTOMER][NEUTRAL] Yeah, it is $55 even.
[AGENT][NEUTRAL] And the name of the facility you're calling from, Ms. [PII]?
[CUSTOMER][NEUTRAL] Uh, yeah, the facility name is Ana Clinic.
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold while I look up this claim and I'll be right back with you.
[CUSTOMER][NEUTRAL] Uh yes, please.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding for me, [PII].
[AGENT][NEUTRAL] I have the claim information for you. The claim number is 3592999.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] The claim was denied because office visits are not covered under the patient's policy.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Outpatient office visits are not covered, right?
[AGENT][NEUTRAL] Office visits are not covered under the patient's policy.
[CUSTOMER][NEUTRAL] And the patient policy.
[CUSTOMER][NEUTRAL] Uh, may I know who is responsible for that?
[AGENT][NEGATIVE] We don't give patient responsibility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It is, just give me a second.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, can you please uh spell out your name for me?
[AGENT][NEUTRAL] Yes ma'am, it's [PII]
[CUSTOMER][NEUTRAL] [PII] And uh
[CUSTOMER][NEUTRAL] What is the call reference number?
[AGENT][NEUTRAL] It would be my name and today's date.
[CUSTOMER][NEUTRAL] Yep, should you move to the next one.
[AGENT][NEUTRAL] Yes ma'am. What is the next patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Yeah, just give me a second. I'll help you with that. Just for a second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] The next uh member ID is 785511.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] And what is the member's name and date of birth?
[CUSTOMER][NEUTRAL] Uh yes, it is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, and what the data service and the charge amount?
[CUSTOMER][NEUTRAL] Uh yes. The date of service is [PII] with the total charge amount of $355 even.
[AGENT][NEUTRAL] OK, and the charges after the primary insurance paid?
[CUSTOMER][NEUTRAL] Uh yeah. Just give me a second. I'll help you with that. Just a second. Yeah. It is $80 even.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, and is it still for [PII] or is it a different facility?
[CUSTOMER][NEUTRAL] Uh, just give me a second. I'll help you with that.
[CUSTOMER][NEUTRAL] It is with [PII].
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold while I look this one up, Miss [PII], and I'll be right back.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding for me, Miss [PII]. I've got the claim ready for you. The claim number is 3591676.
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] The claim was denied because the benefits were maxed for the calendar year.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hello, did you hear me?
[CUSTOMER][NEUTRAL] Yeah, yes, yes.
[CUSTOMER][NEUTRAL] I can hear you.
[AGENT][NEUTRAL] OK, did you get the claim number?
[CUSTOMER][POSITIVE] Yeah, I got it.
[AGENT][NEUTRAL] Did you get the reason why it was denied?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEGATIVE] The reason why it was denied was because the calendar year benefit has been maxed.
[CUSTOMER][NEUTRAL] Sorry, it is denied for max benefits?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Max benefits. How many units are met, may I know?
[AGENT][NEUTRAL] I'm sorry, can you repeat the question?
[CUSTOMER][NEUTRAL] How many units were met?
[AGENT][NEUTRAL] It does not go by units.
[CUSTOMER][NEUTRAL] Then
[AGENT][NEUTRAL] OK, let me look.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It goes by benefit amount.
[AGENT][NEUTRAL] And the outpatient
[CUSTOMER][NEUTRAL] OK, what is the dollar amount?
[AGENT][NEUTRAL] The dollar amount for outpatient is 4, I'm sorry, $1600 per calendar year.
[CUSTOMER][NEUTRAL] And how many daughters were met?
[AGENT][NEUTRAL] All of it
[CUSTOMER][NEUTRAL] Just give me a second.
[CUSTOMER][NEUTRAL] Can you please come again with the denial reason claim is denied for?
[AGENT][NEUTRAL] The calendar year benefits for the calendar year were maxed out. He used up all his money.
[CUSTOMER][NEUTRAL] Sorry, can you, yeah, uh, for documentation purpose, I'm asking you, calendar.
[AGENT][NEUTRAL] Calendar year benefit was maxed.
[CUSTOMER][NEUTRAL] Benefit, sorry, the calendar year benefit?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] After that, can you please finish that sentence?
[AGENT][NEUTRAL] Was maxed out.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Exhausted.
[CUSTOMER][NEUTRAL] Was maxed out.
[CUSTOMER][NEUTRAL] Just give me a second.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Exhausted.
[CUSTOMER][NEUTRAL] It is denied for the calendar year then was accepted, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. It goes with
[CUSTOMER][NEUTRAL] It goes with the dollar amount, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Oh then.
[CUSTOMER][NEUTRAL] Amount
[CUSTOMER][NEUTRAL] How many were met, May I know?
[AGENT][POSITIVE] The whole whole amount was met. There's nothing left.
[CUSTOMER][NEUTRAL] $1600 even were met, right?
[AGENT][NEGATIVE] $1600 and this is just to verify benefits it's not a guarantee of payment. They had a calendar year benefit amount of $1600 per calendar year and they exhausted the whole benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And exhausted the whole.
[CUSTOMER][NEUTRAL] A month. May I know who is responsible for the remaining balance?
[AGENT][NEGATIVE] We don't give patient responsibility.
[CUSTOMER][NEUTRAL] Is it patient responsibility or is the provider?
[AGENT][NEUTRAL] We don't give the responsibility of the patient or the provider.
[CUSTOMER][NEUTRAL] Whom do we need to reach out for this?
[AGENT][NEUTRAL] That would depend on the provider and how they want to reach out.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Just give me a second.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, so you want the next one, same patient but different date of service.
[AGENT][NEUTRAL] OK, what's the next data service?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] The next stage of service is.
[CUSTOMER][NEUTRAL] [PII] with the total charge amount of $975.82.
[AGENT][NEUTRAL] OK, and the charges after the primary insurance paid?
[CUSTOMER][NEUTRAL] It is $80.41.
[AGENT][NEUTRAL] 841 OK, and is it for the same facility for [PII]?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold. I'm gonna look this one up. I'll be right back.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Bye
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you, Ms. [PII], for holding for me on this one, the claim number is 359.
[CUSTOMER][NEUTRAL] A
[AGENT][NEUTRAL] 1675 and it was denied for the same reason the calendar year benefit has been maxed out.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Yeah, when it
[CUSTOMER][NEUTRAL] Yeah, may I know the, uh, may I know the date when it was met?
[AGENT][NEUTRAL] Let me look and see if I can find that.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] I can't give that information that was not your facility.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEGATIVE] I cannot give that information. The facility that it was met with was not yours.
[CUSTOMER][NEGATIVE] You will not provide the
[CUSTOMER][POSITIVE] Yeah, fine. Thank you so much. Have a nice day.
[AGENT][POSITIVE] You're welcome you have a beautiful day too and.