AccountId: 011433970860
ContactId: 4d07134d-b8ec-4f36-b191-3ccd41ed087b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 708640 ms
Total Talk Time (AGENT): 162799 ms
Total Talk Time (CUSTOMER): 171639 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/4d07134d-b8ec-4f36-b191-3ccd41ed087b_20250416T16:16_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah, hi, this is [PII] calling from Forest office checking on it, uh, denied claim.
[AGENT][NEUTRAL] Hey [PII], I can help you with uh claim status. Do you have a good callback number?
[CUSTOMER][NEUTRAL] [PII]. It's a direct line. And please spell your name?
[AGENT][NEUTRAL] And it's [PII], it's [PII] First initial [PII] last name, [PII].
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] OK, do you have the policy number of the patient?
[CUSTOMER][NEUTRAL] Yes, the policy number I have D as in Delta 42005319.
[AGENT][NEUTRAL] And what's the last name of the patient?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] How do you spell that?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And first name?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII] or?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Is this for uh medical services or dental?
[CUSTOMER][NEUTRAL] Medical.
[AGENT][NEUTRAL] And the patient's date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, what was that date of service?
[CUSTOMER][NEUTRAL] [PII] and the bill amount $170 even.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Uh, looks like we received that 521-2024.
[AGENT][NEUTRAL] Uh, process the same day and
[AGENT][NEUTRAL] Let's
[AGENT][NEUTRAL] Uh, calendar year maximum, uh, has been met.
[CUSTOMER][NEUTRAL] So maximum benefits has been met?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Is it by number of visits or by dollar value?
[AGENT][NEUTRAL] Um, let me see, I think it's a number of visits. Let me double check.
[AGENT][NEUTRAL] Uh, it's number of visits, 4.
[CUSTOMER][NEUTRAL] When was the last visit used?
[AGENT][NEUTRAL] Um, I, I can give you the claim status. That's all I can give is claim status.
[AGENT][NEUTRAL] For the claim you're asking about.
[CUSTOMER][NEUTRAL] So you can't provide when was the last visit? OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] And I do see that we have submitted an appeal on this one.
[CUSTOMER][NEUTRAL] Through fax
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] [PII]. Could you check have you received any appeal?
[AGENT][NEUTRAL] Um, I don't show anything on file.
[CUSTOMER][NEUTRAL] Can you double check because we have submitted the appeal twice.
[AGENT][NEUTRAL] Yeah, I'm not, I'm not showing an appeal on file.
[AGENT][NEUTRAL] And the max is met, so I'm not sure what it is to appeal, so.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEGATIVE] So we should not submit an appeal for this type of dinner now.
[AGENT][NEUTRAL] Uh, I mean, you can. It's just this is a limited hospital indemnity plan, so it's, it is a limited plan.
[AGENT][NEUTRAL] It just has specific parameters for certain services, so.
[AGENT][NEGATIVE] But I don't show an appeal on file.
[CUSTOMER][NEUTRAL] And what, uh what is the time frame to submit an up to?
[AGENT][NEUTRAL] Uh it'd be 180 days from the process date.
[CUSTOMER][NEUTRAL] And the fax number?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mailing address?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] And can I have the claim number?
[AGENT][NEUTRAL] Uh, claim number is 3456116.
[CUSTOMER][NEUTRAL] I do have one more data service for this member. Could you help me with that?
[AGENT][NEUTRAL] Uh, sure. What's that date?
[CUSTOMER][NEUTRAL] Just a second, let me open it up.
[CUSTOMER][NEUTRAL] [PII] and the bill amount $141 even.
[CUSTOMER][NEGATIVE] I think this one also denied for the same reason.
[AGENT][NEUTRAL] Um, let me see.
[AGENT][NEUTRAL] Uh yeah, process 4-11-2024, uh, and denial on 56 2024.
[CUSTOMER][NEUTRAL] So when it was in 56, right?
[AGENT][NEUTRAL] Yes, 56 2024.
[AGENT][NEUTRAL] And it looks like, let's see.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And for this one, do you see any appeal on file?
[AGENT][NEUTRAL] Uh, let me see.
[AGENT][NEUTRAL] 3451593.
[AGENT][NEGATIVE] Uh, we received a second claim and then it was denied for the same the denied for maximum has been met.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Can I have the reference number for this member?
[AGENT][NEUTRAL] That's just my name and today's date.
[CUSTOMER][NEUTRAL] And [PII], I do have one more member with one client. Can you help me with that?
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, what's that policy number?
[CUSTOMER][NEUTRAL] 02563525
[AGENT][NEUTRAL] And patient name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII] and date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And date of service?
[CUSTOMER][NEUTRAL] Just a second, let me open it up.
[CUSTOMER][NEUTRAL] [PII] and the bill amount $298 even.
[AGENT][NEUTRAL] OK, it looks like we received that 182025, um, that was paid on 19-2025, uh, made a payment of $75.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] [PII], I want to let you know I do have the payment information on my end on this claim, the CPTJ 3301 and 96372 was denied and I, I need further information on the denial.
[AGENT][NEUTRAL] So the maximum payout for the date of service was meant, 75 is the maximum payout for the date of service.
[CUSTOMER][NEUTRAL] For the.
[CUSTOMER][NEUTRAL] So for data service the maximum payable amount is $75 right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] And so in this case, can we go ahead and build the member for the remaining?
[AGENT][NEUTRAL] Um, we don't determine patient responsibility. We just process the claims according to their policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] And can you able to fax me the UOB?
[AGENT][NEUTRAL] Your facts.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, I'll get that faxed over. It just takes a few minutes.
[CUSTOMER][NEUTRAL] OK, can I have the claim number?
[AGENT][NEUTRAL] 354-755-59.
[CUSTOMER][NEUTRAL] And the reference number would be your name and today's date.
[CUSTOMER][POSITIVE] And thanks [PII]. Thanks for the information. That's all the information I needed. Thank you. Have a great day and stay safe. Bye bye.
[AGENT][POSITIVE] OK, thanks for calling APL you as well.