AccountId: 011433970860
ContactId: 42fd9195-6c48-4fe5-9cbf-c3602bcafa29
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 486130 ms
Total Talk Time (AGENT): 104294 ms
Total Talk Time (CUSTOMER): 156188 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/07/42fd9195-6c48-4fe5-9cbf-c3602bcafa29_20250507T15:33_UTC.wav
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[CUSTOMER][NEUTRAL] Hello, could you hear me?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] I'm sorry. Hello, can you hold me?
[AGENT][NEUTRAL] Yes, uh, this is [PII]. How can we help you?
[CUSTOMER][NEUTRAL] Uh, I can hear you.
[CUSTOMER][NEUTRAL] Hi, this is [PII] and I'm calling for provider to check on additional information about the claim that has denied. Please note this call will be monitored and recorded for quality and training purposes. How are you doing today?
[AGENT][POSITIVE] I'm doing well how are you?
[CUSTOMER][POSITIVE] Nice to hear that. I'm also good.
[AGENT][POSITIVE] OK, and I can definitely get some clarification regarding that claim. um can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] Yes, our callback number is [PII] and it's a direct line. And can I get your name one more time?
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Of course. Do you have that policy number?
[CUSTOMER][NEUTRAL] Yes, I have. That is 02361734.
[AGENT][NEUTRAL] OK and then what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] For this claim, patient name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] Thank you for verifying that. Do you have the claim number?
[CUSTOMER][NEUTRAL] Yes, I have.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, shall I provide that claim number with you?
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] Uh, for this claim, that claim number, I have here is 359-0230.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] She'll
[AGENT][NEUTRAL] OK, so this, uh, particular claim, uh, was a duplicate, OK, so if you'll give me one moment, I'll try to find that original claim. Give me just a moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I have the original claim number. Shall I provide with you?
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Uh yes, please.
[CUSTOMER][NEUTRAL] The original claim number I have yours is 3518375.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, so for this claim we were unable to pay that benefit as their outpatient benefit for the calendar year had been met.
[CUSTOMER][NEUTRAL] One moment
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So for this claim, you're recently submitted on [PII]. And that claim number which I provide with you, uh it's 359-0230. Is it right? And that was done as a duplicate.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Yeah, that was the one that you sent me, yes. That's correct.
[CUSTOMER][NEUTRAL] OK. And may I know the reason why it was done as a duplicate?
[AGENT][NEGATIVE] If it was the same information and it had previously denied.
[CUSTOMER][NEUTRAL] OK. So it was done as a duplicate on
[CUSTOMER][NEUTRAL] [PII] because original claim was processed correctly.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And original claim was denied on.
[CUSTOMER][NEUTRAL] I could see [PII].
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just 1 2nd.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So that claim number 3518375.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And that code 63047 has been denied for outpatient benefit per calendar year was met.
[AGENT][NEUTRAL] That's correct. The benefit amount for the calendar year had been met. There was nothing additional for us to pay.
[CUSTOMER][NEUTRAL] So what this means it was exceeded the dollar amount, is it right?
[AGENT][POSITIVE] Yes, that's right.
[CUSTOMER][NEUTRAL] And may I know that when it was made and how much you are allowed for this member? Can I get that information?
[AGENT][NEUTRAL] The benefit amount allowed for this number is $3000 per calendar year.
[AGENT][NEGATIVE] And uh I'm unable to give that information as to when it was met as that was through a different provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Just one moment
[CUSTOMER][NEUTRAL] Just 1 2nd.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Thank you so much for your patience. And for this claim, you said per calendar year. So for this mean it was start with [PII] and it was end of [PII]?
[AGENT][NEUTRAL] Yes, it's the calendar year. Yes, however, this claim took place in [PII].
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] So what this mean start with [PII] and it was the end of [PII].
[AGENT][NEUTRAL] Yes, as it goes from the date of service.
[AGENT][NEUTRAL] Not when we received the claim.
[CUSTOMER][NEUTRAL] Uh, so,
[CUSTOMER][NEUTRAL] Can I get that when that calendar year was started?
[AGENT][NEUTRAL] It, yes, I mean for for every year it does start, uh, [PII] every year.
[CUSTOMER][NEUTRAL] Do you have the date?
[CUSTOMER][NEUTRAL] Thank you. OK. And can I get the call reference number for this member?
[AGENT][NEUTRAL] That would just be my first name, last initial, and today's date and so my last initial is [PII], was there anything else I could help you with, [PII]?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Uh, no, that's all. Thank you so much for assisting me and have a day for you. Bye.
[AGENT][POSITIVE] Of course, yeah, thanks for calling ATL. You too, bye bye.