AccountId: 011433970860
ContactId: 40ce6914-ab51-4187-83cb-26326d5daf01
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 726080 ms
Total Talk Time (AGENT): 142469 ms
Total Talk Time (CUSTOMER): 236304 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/40ce6914-ab51-4187-83cb-26326d5daf01_20250219T14:36_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] and I'm calling on behalf of provider's office and I'm looking for the claim status for one of the members.
[AGENT][NEUTRAL] OK, do you have a callback number I can get in case we get disconnected I can call you back.
[CUSTOMER][NEUTRAL] Yeah, the callback number for me is [PII].
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEGATIVE] This is a direct line, no extension.
[AGENT][NEUTRAL] OK, it's [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, can you give it to me one more time, please? [PII].
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII]. OK, thank you. And do you have a policy number?
[CUSTOMER][NEUTRAL] Yeah, I have a member ID number.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the member ID number is D like Delta.
[CUSTOMER][NEUTRAL] 43410142.
[AGENT][NEUTRAL] That's not one of our policy numbers. Do you have the Social Security number?
[CUSTOMER][NEUTRAL] This is not your policy number. Uh, I'm trying to call, uh, I mean, uh, is it IE Insurance?
[AGENT][NEUTRAL] This is American Public Life Insurance. Do you have their social? I can see if there's a policy in our system.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, OK. Just give me a moment. Let me check. I have the Social Security. OK, so sorry, I don't have the social security number. Is there any other way to find a number with the name or with the date of birth?
[AGENT][NEUTRAL] Who
[AGENT][NEUTRAL] Whose name?
[CUSTOMER][NEUTRAL] OK. First name is [PII] and it's [PII], it's [PII]
[AGENT][NEUTRAL] OK, I'm sorry, spell the last name again?
[CUSTOMER][NEUTRAL] It's [PII]
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] What state do they live in?
[CUSTOMER][NEUTRAL] Uh, talking about member, members, uh, living in, uh, [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Is this for medical?
[CUSTOMER][NEUTRAL] Yeah, this is for medical.
[AGENT][NEUTRAL] What's their date of birth?
[CUSTOMER][NEUTRAL] Date of birth for the member is [PII].
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, thank you, [PII], and you were calling for a claim status?
[CUSTOMER][POSITIVE] Yeah, correct.
[AGENT][NEUTRAL] OK, I can look that up for you. What date of service?
[CUSTOMER][NEUTRAL] Date of service for the claim is 2-19-2024.
[CUSTOMER][NEUTRAL] Do you require the total charge as well?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, is this for a facility bill, doctor's charge, anesthesia?
[CUSTOMER][NEUTRAL] Uh, this is, uh, regarding the anesthesia code 01214.
[AGENT][NEUTRAL] 4, OK, hold on one moment.
[CUSTOMER][NEUTRAL] It's
[AGENT][NEUTRAL] OK, it looks like we paid $125 on that.
[CUSTOMER][NEUTRAL] Yeah, um, we do receive the payment for this one, but, uh, I just want to, like there is in denial as that that out of my network payment hold or something benefit maximum for this time period is ofness has been recorded something.
[CUSTOMER][NEUTRAL] Like, uh, the expected amount in this name are basically is $2310 and we received only $125 and there is an uh CPT code of 64447 as well in that particular claim, and that got denied. So I just want to uh review that status, basically.
[AGENT][NEUTRAL] OK, um, it, the max was met. That's why we only paid the 125.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK, so, like the, there is a coverage basically uh for the member's plan and the max benefit for particular services and uh that basically meant and, and after that you didn't pay for the other one and the rest of that is patient responsibility, is it?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK. Uh, so,
[CUSTOMER][NEUTRAL] Uh, just give me a moment. Can you please help me with the one, firstly, with the receive date, precise date, and the claim number?
[AGENT][NEUTRAL] The claim number is 3430091.
[CUSTOMER][NEUTRAL] OK. And what was the receipt date for the claim?
[AGENT][NEUTRAL] Hold on.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It was received 3-11-24.
[AGENT][NEUTRAL] It was page 314.
[CUSTOMER][NEUTRAL] OK, uh, thank you for that information as well. Um, can you please explain me the, uh, benefit scenario once again, like the denial reason basically.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Explain the benefits again.
[CUSTOMER][NEUTRAL] Uh, no, the denial. I just want to understand that that, uh, um, the max benefit in that one, like, uh, you just, uh, set the particular amount to the member and uh that basically ended with this, uh, with that $1125 and that's next benefit is met. So after that patient is uh responsible for, uh, any other, uh, like other responsibility.
[AGENT][NEUTRAL] Right, correct, you're correct. So what else do you want me to explain?
[CUSTOMER][NEUTRAL] So, oh, OK.
[CUSTOMER][NEUTRAL] Uh, no, no, no, I just want to ask you like what is the maximum, uh, benefit amount for the member.
[AGENT][NEUTRAL] Uh, hold on just a moment. I can transfer you. Somebody can tell you, OK?
[CUSTOMER][POSITIVE] OK, thank you for that one. And uh can you please help me with your name once again?
[AGENT][NEUTRAL] My name is [PII]
[CUSTOMER][POSITIVE] OK, [PII]. Thank you for the information that you provided to me and you can transfer my call now.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] Deferring.
[CUSTOMER][NEUTRAL] Sing.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], I have a man on the phone that needs some help with the HR policy.
[CUSTOMER][NEUTRAL] OK, what's that policy number?
[AGENT][NEUTRAL] His name is [PII].
[AGENT][NEUTRAL] The policy number is 02356765.
[AGENT][NEUTRAL] His callback number is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] He's calling on claim number 3430091.
[AGENT][NEUTRAL] The anesthesia charge. I told him we paid 125 and the max was met. He wants to know what the max met and all that is for the anesthesia.
[CUSTOMER][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] And I wasn't sure.
[CUSTOMER][NEUTRAL] Mm, OK, I'm gonna have to find the surgery charge because it's gonna be a percentage.
[CUSTOMER][NEUTRAL] Just a second, see if I can pull up that surgery real quick.
[CUSTOMER][NEUTRAL] Alright, room and board.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Oh, I see.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I got it.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Bye bye.