AccountId: 011433970860
ContactId: 45da51aa-6c87-4c64-ac94-a2bb7baf05a0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 932250 ms
Total Talk Time (AGENT): 330853 ms
Total Talk Time (CUSTOMER): 229619 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/09/45da51aa-6c87-4c64-ac94-a2bb7baf05a0_20250409T18:05_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello [PII], this is [PII] calling from provider's office to check up on a claim status. Also, this call has been recorded for quality train and training purposes. Are you OK with that?
[AGENT][NEUTRAL] That is fine. And I'm sorry, what was your name again?
[CUSTOMER][NEUTRAL] Uh, it's [PII] spelled as [PII] my [PII] name would be [PII]. Uh and you said your name is [PII]. Is it [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] No.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] First initial and last name, [PII].
[AGENT][NEUTRAL] And [PII], what is your callback number? Oh, you're welcome.
[CUSTOMER][POSITIVE] Thank you so much, [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, it would be [PII].
[AGENT][NEUTRAL] OK, thank you. And how many claims do you have to check status on today, [PII]?
[CUSTOMER][NEUTRAL] I do have 2 claims with me.
[AGENT][NEUTRAL] OK. Are they for the same patient or for different patients?
[CUSTOMER][NEUTRAL] No, the both of the claims are for different members.
[AGENT][NEUTRAL] OK, so you will use my name along with today's date as your call reference number for each one.
[AGENT][NEUTRAL] Also, any information that I provide for claims will be a verification of benefits and not a guarantee of payment.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Lastly, if you need a cop if we do have a claims on copy of the explanation of benefits.
[AGENT][NEUTRAL] Once you have the claim number, you can print the explanation of benefits from our portal by going to [PII].
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK. And what is your first patient's policy number, please?
[CUSTOMER][NEUTRAL] Yeah it would be 01.
[CUSTOMER][NEUTRAL] 845857 M as in Mike L as in Lima number 8.
[AGENT][NEUTRAL] OK, thank you. One moment please. I'd like.
[AGENT][NEUTRAL] Get the member's information pulled up.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And what is your patient's name, [PII] and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it's [PII] and the date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And what is the date of service and total bill amount for her place?
[CUSTOMER][NEUTRAL] D of service was uh [PII] together with the charge amount $500 even.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] One moment please.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so this client has been received multiple times. Do you want the most recent receipt?
[AGENT][NEUTRAL] The claim was denied the duplicate. Do you want the original claim exemption?
[CUSTOMER][NEUTRAL] Uh, can you help me with the most recent claim?
[AGENT][NEUTRAL] Claim number is 356-074-1.
[AGENT][NEUTRAL] And it was denied as a duplicate of previously submitted expenses.
[CUSTOMER][NEUTRAL] OK. And uh what about the previous one?
[AGENT][NEUTRAL] So, OK, you need the original claims information also?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That claim number is 3462771.
[AGENT][NEGATIVE] That claim was also denied.
[AGENT][NEUTRAL] And the reason for the denial on this claim states outpatient benefits for this calendar year has
[AGENT][NEUTRAL] Be met.
[CUSTOMER][NEUTRAL] OK. And uh
[CUSTOMER][NEUTRAL] How much is that amount?
[CUSTOMER][NEUTRAL] For calendar year.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] How much, how much is the maximum, yeah.
[AGENT][NEUTRAL] On the
[AGENT][NEUTRAL] Yes, on this supplemental policy, the maximum outpatient benefit per calendar year for covered outpatient services is $1000 with no outpatient deductibles.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And when was this met?
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It was met with the claim received prior to your claim. It was met in May.
[AGENT][NEUTRAL] Of
[CUSTOMER][NEUTRAL] In
[AGENT][NEUTRAL] 924.
[CUSTOMER][NEUTRAL] May
[AGENT][NEUTRAL] But I can't provide details on that with providers.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Yes, ma'am. It was for another claim that was processed prior to yours being received.
[CUSTOMER][NEUTRAL] Can you again repeat that date?
[AGENT][NEUTRAL] The claim that we processed was processed in [PII].
[CUSTOMER][NEUTRAL] OK, [PII].
[CUSTOMER][POSITIVE] Sure, no problem. Thank you so much uh for your help for this number.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, and you said that you have one more patient, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] And I actually do have 2 claims for the same date of service.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] For the next member?
[AGENT][NEUTRAL] For the next policy you have 22 different claims for the same data service, is that correct?
[CUSTOMER][NEUTRAL] Yeah, the
[CUSTOMER][POSITIVE] That's right.
[AGENT][NEUTRAL] OK, so give me just a moment to get um to where I can pull up the other policy members' information. [PII], one moment.
[CUSTOMER][NEUTRAL] Sure, yeah.
[AGENT][NEUTRAL] OK. And what is your next patient's policy number, please?
[CUSTOMER][NEUTRAL] It would be 01.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] 68478 M as in Mike L as in Lima number 8.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, we missed a number somewhere. 0 you said 0168478?
[AGENT][NEUTRAL] Was the first, is that correct?
[CUSTOMER][POSITIVE] Yeah, 01684 yeah that's right.
[AGENT][NEUTRAL] OK, so we're missing a number there.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK, I do have a member ID card with me and the number would be 0216878478 M as in Mike L as in Lima number 8.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so on the first number, the first, um, what you initially gave me, you did not have the 2 in there.
[AGENT][NEUTRAL] You're missing, you were missing the 2.
[CUSTOMER][POSITIVE] Yeah that's right.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Alright, so just one moment for me to get this member's information pulled up.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it's [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is the date of service and total bill amount?
[AGENT][NEUTRAL] The first claim?
[CUSTOMER][NEUTRAL] Yeah, the date of service is [PII], together with the bill amount $500 even.
[AGENT][NEUTRAL] Alright, one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So the claim was received, the claim number is 357.
[AGENT][NEUTRAL] 8345.
[AGENT][NEUTRAL] This claim
[AGENT][NEUTRAL] There was a benefit paid in the amount of $40.
[AGENT][NEUTRAL] And that was paid on single check.
[AGENT][NEUTRAL] 2034058.
[CUSTOMER][NEUTRAL] Is it 203?
[AGENT][NEUTRAL] That is correct. 4058.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this was issued on [PII].
[CUSTOMER][NEUTRAL] When was this paid?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said that you also have another claim for the same date of service. Is that correct, Corona?
[CUSTOMER][NEUTRAL] Yes, it's for the same date of service, uh, with the charge amount $669.63.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, this claim was also received?
[AGENT][NEUTRAL] The claim number is 357.
[AGENT][NEUTRAL] 8336.
[AGENT][NEUTRAL] There was a benefit paid in the amount of $40.
[AGENT][NEUTRAL] And that was paid on single check 2034059.
[AGENT][NEUTRAL] And that check was also issued on
[AGENT][NEUTRAL] Give me one, I believe it was the same date.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Just one moment.
[CUSTOMER][POSITIVE] Yeah, sure, no problem.
[AGENT][NEUTRAL] It was, yes, it was also shoot on [PII].
[AGENT][NEUTRAL] Now on this
[AGENT][NEGATIVE] Claim in addition to the $40 benefit paid that was denied.
[AGENT][NEUTRAL] And the denial remark on that states, insured, well, insured's major medical cover.
[AGENT][POSITIVE] provided full benefits for this procedure that's are payable.
[CUSTOMER][NEUTRAL] But you said the claim has been paid with $40 right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK. Uh, can you just help me with the pay to address on which address you have, uh, issued a check?
[AGENT][NEUTRAL] What is the tax ID number?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. The address is [PII].
[CUSTOMER][POSITIVE] Yeah, that's the uh correct address. OK, sure. Thank you so much for your help.
[AGENT][NEUTRAL] You're welcome. So again, is there anything else that I can help you with today, [PII]?
[CUSTOMER][NEUTRAL] Uh, no, and you said the call reference number would be your name and today's date, right?
[AGENT][POSITIVE] That is correct. Yes, ma'am.
[CUSTOMER][POSITIVE] OK. Thank you so much for your help, [PII]. Hope you have a wonderful day.
[AGENT][NEUTRAL] OK. Well,
[AGENT][POSITIVE] OK, well then I hope you do too if that's all I can help you with, thank you again for calling APL.
[CUSTOMER][POSITIVE] Bye bye take care.
[AGENT][POSITIVE] All right, thank you. You too. Bye bye.