AccountId: 011433970860
ContactId: 479a0aad-a760-409b-b860-5777ccc38b8c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 689770 ms
Total Talk Time (AGENT): 218045 ms
Total Talk Time (CUSTOMER): 258559 ms
Interruptions: 5
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/18/479a0aad-a760-409b-b860-5777ccc38b8c_20250618T22:51_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Mm, hi, [PII], this is [PII] calling from provider's office to check the claim status. Uh, I think we have spoken before, right, regarding the claim.
[AGENT][NEUTRAL] Oh yes, I, I think we just got off the phone. Yes, sir.
[CUSTOMER][NEUTRAL] Oh yes, it's for the same.
[AGENT][NEUTRAL] OK we we needing to check on a different claim?
[CUSTOMER][NEUTRAL] Uh, no, it's for the same claim. I just have a query about that one.
[AGENT][NEUTRAL] OK, give me just a moment let me get that information pulled back up.
[CUSTOMER][NEUTRAL] Mm. Sure, sir.
[AGENT][NEUTRAL] OK, and uh really quick time, I apologize, uh, if you wouldn't mind, um, could you, uh, verify the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure, sure. Uh first name is [PII]. It's [PII] and last name is [PII]. It's [PII]
[CUSTOMER][NEUTRAL] So, date of birth [PII].
[AGENT][NEUTRAL] OK, thank you so much. OK, so you had a question about the same claim that was uh 355-596-3?
[CUSTOMER][NEUTRAL] Mm, yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm, yes.
[AGENT][NEUTRAL] OK, go ahead, I've got that information pulled up.
[CUSTOMER][NEUTRAL] Uh, yes, uh, just ask it to that the maximum benefits is $250 right? $250.
[AGENT][NEUTRAL] That's correct per calendar year.
[CUSTOMER][NEUTRAL] Uh, yes, but for this calendar year, the total amount paid is just $209 even.
[AGENT][NEGATIVE] No sir, that's not correct.
[CUSTOMER][NEUTRAL] Uh, but this.
[AGENT][NEUTRAL] No, so there was a claim previously filed, uh, for the remaining $78 excuse me, um, but it was from a different provider, so I'm just unable to disclose that information regarding that claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] So from the same provider that you're with um we did pay a benefit of $172 that remaining balance was paid prior to that from a different provider.
[CUSTOMER][NEUTRAL] Oh, OK, OK, OK.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Let's pay to different provider, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK, just a moment.
[CUSTOMER][NEUTRAL] OK. Uh please, may I know what is the date of service which was built to the different provider? It's the, it's the same door.
[AGENT][NEUTRAL] Sure, it was all on the same date of service, yes, it's all on, uh, [PII].
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK. Just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, give me a moment.
[AGENT][NEUTRAL] Of course.
[CUSTOMER][NEUTRAL] So one was paid for $172 right?
[AGENT][NEUTRAL] Yes, that was from the same provider that you gave me that information the Summit radiology services that was that same provider, uh, the remaining balance went to a different provider.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And that paid amount is $79. Uh, that what you say that.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Yeah, that paid amount is $79.
[AGENT][NEUTRAL] 78.
[CUSTOMER][NEUTRAL] The 78, just a moment.
[AGENT][NEUTRAL] Yes, to make 250, sure.
[CUSTOMER][NEUTRAL] 17.
[CUSTOMER][NEUTRAL] OK, but just a moment. Because I do see here for the same provider, the payment for $37 it was already made to [PII]. Mhm.
[AGENT][NEUTRAL] That was a different.
[AGENT][NEUTRAL] Right, that was a different, um, that's not a diagnostic benefit. That was that fell under their outpatient sickness benefit.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] So that was a separate um right.
[CUSTOMER][NEUTRAL] OK, OK, just a moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Just a moment. So there is no the diagnostic benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I think I'm gonna.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][POSITIVE] Thank you so much for your patience, care. So, yeah, thank you so much. And just now I got clarified. And I have one more claim for a different member under the same tax ID. Shall we check for that?
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] Uh, yes, give me just a moment.
[CUSTOMER][NEUTRAL] Sure, sure, sure.
[AGENT][NEUTRAL] OK, and then just to clarify that tax ID was [PII]?
[CUSTOMER][NEUTRAL] Mm, yes, yeah.
[AGENT][NEUTRAL] OK, OK, um, do you have that policy number?
[CUSTOMER][NEUTRAL] Mm, yes. It is 0, yeah, 02517281.
[AGENT][NEUTRAL] OK, go ahead.
[AGENT][NEUTRAL] OK, and then, uh, what was the name and date of birth for this member please?
[CUSTOMER][NEUTRAL] Oh yeah, it's [PII]. Date of birth [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that. What was the date of service for this claim?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh yes, it's [PII].
[AGENT][NEUTRAL] OK, and then uh that go ahead.
[CUSTOMER][NEUTRAL] Charge amount $25 yeah, $25 even.
[AGENT][NEUTRAL] 25. OK, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, so for this claim, uh, the benefit maximum for the date of service had been met, uh, so we were unable to pay that benefit. Did you need a copy of this EOB?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, yes, I think I have that one. But just like the previous one, what is the total benefits for this current?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh sure.
[AGENT][NEUTRAL] Sure, so for this benefit it's their outpatient sickness benefit and that pays at $75 per calendar day.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, and give me just a moment. I'll take a look at when that was. I imagine it's the same day, but hang on.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] On the [PII], yes, and that was paid to a different provider.
[CUSTOMER][NEUTRAL] OK. Just $75 allowed per day, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] It was paid to different provider, OK.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] And the service is for our patient service.
[AGENT][NEUTRAL] Yes, that's uh their outpatient sickness benefit.
[CUSTOMER][POSITIVE] OK, got it. Thanks for that. Just a moment.
[CUSTOMER][NEUTRAL] OK. And this one more claim for 1142025.
[AGENT][NEUTRAL] I said this was for the same member. I'm sorry.
[CUSTOMER][NEUTRAL] It's for $30 even.
[CUSTOMER][POSITIVE] Oh yes, for the member, yeah.
[AGENT][NEUTRAL] OK, sorry about that uh what was that amount?
[CUSTOMER][NEUTRAL] Yeah, $30 even for 1 14 2025.
[AGENT][NEUTRAL] 30
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Hm
[AGENT][NEUTRAL] And that was 114.
[CUSTOMER][NEUTRAL] Mhm, yes.
[AGENT][NEUTRAL] OK, alrighty, one moment.
[AGENT][NEUTRAL] OK, I apologize it looks like we might have received this claim a couple of different times. Let me find that original.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm. Yes.
[AGENT][NEUTRAL] OK, so I did find that original claim, uh, this one denied for the same reason as that, uh, benefit maximum for the date of service had been met, uh, and I do see where that was paid again it was that $75 to a different provider.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But we can't get the provider or claim number information right?
[AGENT][NEUTRAL] I can give you this claim information but not the one that we paid on us that is from a different provider.
[CUSTOMER][NEUTRAL] OK, sure. So, may I know the original claim number, the denied one?
[AGENT][NEUTRAL] Oh yes, that is 35.
[AGENT][NEUTRAL] 60.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 128.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] 3560128. Got that. Thanks for that care. OK.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And also, may I know the date for the original claim?
[AGENT][POSITIVE] Oh yes, give me just a moment, I'll get that for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, oh, this claim was received [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] And it was also processed on [PII].
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][POSITIVE] Thanks for that care. So, yeah, that's it. Mm, no more claims. Thank you so much for your patience. Have a great day. Happy evening. Stay safe. Yeah, bye-bye.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Of course.
[AGENT][POSITIVE] You too thank you bye bye.
[CUSTOMER][NEUTRAL] Mhm