AccountId: 011433970860
ContactId: 4c8ec265-b95c-48df-802f-127f62fa6dee
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 893309 ms
Total Talk Time (AGENT): 224636 ms
Total Talk Time (CUSTOMER): 236997 ms
Interruptions: 9
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/08/4c8ec265-b95c-48df-802f-127f62fa6dee_20250508T13:08_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] from Community Medical Associates to check on a claim status.
[AGENT][NEUTRAL] OK, sure, I can assist you with claim status. And Miss [PII], may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, that is [PII].
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] 025123777
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] Alright, thank you.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] And may I have the name of the facility you're calling from, Ms. [PII]?
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] It's my, I'm sorry, uh, it's Medical Associates.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Thank you. May I have the name and date of birth of the patient, Ms. [PII]?
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] [PII] and [PII].
[AGENT][POSITIVE] Perfect. Thank you. May I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, 130 of 2025 for $229 even.
[AGENT][NEUTRAL] OK, so that the date of service [PII] for 229.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I know that.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let me check and see if we have this claim for future, you can check claim status online through our website at [PII] and that's just optional.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] And hm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Give me one moment, let me pull this EP.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, I'm waiting on my system. Do you mind holding for me for a minute?
[CUSTOMER][POSITIVE] Good.
[CUSTOMER][NEUTRAL] Yes, sure.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding and being patient for me, Ms. [PII]. OK, so I have your claim pulled up. Looks like we processed the claim on [PII] and the claim was denied.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Can I have the received date of the claim?
[AGENT][NEUTRAL] The reason for
[AGENT][NEUTRAL] BC date um let me get that that's not on the EOB one moment.
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] 013.
[CUSTOMER][NEUTRAL] that.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, so it was received on [PII] process on [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And can I get the claim number?
[AGENT][NEUTRAL] Claim number is 3589013.
[CUSTOMER][NEUTRAL] OK. Um, can I have the reason for dinner?
[AGENT][NEUTRAL] The denial reason is benefit maximum for the date of service has been met.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] Maximum benefits for the data service.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. Uh, the maximum benefit is allowed, uh, visit wise or dollar wise?
[CUSTOMER][NEUTRAL] I see.
[AGENT][NEUTRAL] This one has a um data service so it's the daily benefits.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. Uh.
[CUSTOMER][NEUTRAL] So, like, ah, one only how many units is allowed to build only?
[AGENT][POSITIVE] It's a per day benefit, so it's gonna be dollar value.
[CUSTOMER][NEUTRAL] Yeah, um, in that case, per day only one time it's allowed or, uh, like how many times it is allowed to bill.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Let me check and see. Let me check her benefits, OK?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, sure, sure.
[AGENT][NEUTRAL] And this is not a guarantee of payment, just a verification of coverage. It looks like this one covers.
[CUSTOMER][NEUTRAL] You.
[AGENT][NEUTRAL] $50 per visit, maximum of 4 visits per person per calendar year.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Only 4 visits are allowed and per calendar year. And when was the last visit met?
[AGENT][NEUTRAL] In a year and it
[AGENT][NEUTRAL] We cannot release that information. I can only give you information pertaining your claim.
[AGENT][NEUTRAL] When we receive your claim, the benefits has been exhausted.
[CUSTOMER][NEUTRAL] When
[CUSTOMER][POSITIVE] OK. Thank you so much. And I actually, for the same number I have one more claim for the same date of service, uh, for the charge amount of $28 even.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] same date.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, OK, one moment.
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah, sure.
[CUSTOMER][NEUTRAL] And before that, can I get a copy of, uh, this is actually patient responsibility, right? We have to bill the member.
[AGENT][NEUTRAL] Let me put this
[AGENT][NEUTRAL] It's up to the provider's discretion. We don't have any contractual involvement. We don't know if they have any other policies out there, and this is not a major medical. This is a limited policy, OK?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] OK, uh, in that case, can I get a UB to my fax number?
[AGENT][NEUTRAL] Yes, what is the fax number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, to your attention.
[CUSTOMER][NEUTRAL] Mm yes.
[AGENT][NEUTRAL] How do you spell your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] So it's [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, um, do you mind holding for me while I send this out to you while I got you on the line, Miss [PII]?
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me Ms. [PII]. OK, I went ahead and send both of them, the one for the 229 and the one for 28, OK?
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Um, but can I have the status of the $20?
[AGENT][NEUTRAL] Yes, uh-huh. Um, OK, so that one was denied stating that veny puncture is not covered. It was received on the same date as the previous [PII] [PII], processed on the same day, [PII].
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] medical.
[AGENT][NEUTRAL] And the claim number on this one is 35890007.
[CUSTOMER][NEUTRAL] ID 611.
[CUSTOMER][NEGATIVE] 358-900-007 then if I'm sir is not uh this is not covered under member plan. This is not.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[AGENT][NEGATIVE] Not cover under the member's plan.
[CUSTOMER][NEUTRAL] Actually remember then so the complete bill amount is members responsible, right? OK call, uh, can I get a call reference number for the call?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's just not covered. The whole amount is not covered. It's not painful.
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Uh, yes, can I have your name?
[AGENT][NEUTRAL] My name is [PII]. That's [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Thank you so much for your assistance. You have faxed both the copy of EOB, right?
[AGENT][POSITIVE] That is correct, yes. Mhm.
[CUSTOMER][POSITIVE] Thank you so much for your assistance. Have a great day.
[AGENT][POSITIVE] You as well thank you for calling APL. Have a good day, Ms. [PII]. Bye bye.