AccountId: 011433970860
ContactId: 50521a5b-9e4a-4d62-823a-14d58181796e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 630940 ms
Total Talk Time (AGENT): 210751 ms
Total Talk Time (CUSTOMER): 256747 ms
Interruptions: 17
Overall Sentiment: AGENT=0.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/21/50521a5b-9e4a-4d62-823a-14d58181796e_20250221T18:18_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So how may I assist you? Hi, my name is [PII] calling from provider's office, checking for claim.
[AGENT][NEUTRAL] OK, sure, I can assist you with claim status, and may I have a callback number just in case we get disconnected, Mr. [PII]?
[CUSTOMER][NEUTRAL] Sure, I can assist you with claim status and may I
[CUSTOMER][NEUTRAL] Yeah, so that number [PII].
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yes, policy number I have. Come on. 02131566.
[AGENT][NEUTRAL] OK, give me one moment, let me pull up this information.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII]. Date of birth of [PII].
[AGENT][NEUTRAL] OK, thank you. May I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] If
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] The charge amount $730 even 730.
[AGENT][NEUTRAL] OK, and that's 113 of 24, correct? [PII]?
[CUSTOMER][POSITIVE] Yes, yes, correct.
[AGENT][NEUTRAL] OK, let me see if I can find this claim for you. And for future, you can check claim status online through our website at [PII] and that's just optional. And let me pull this ELB one moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It.
[CUSTOMER][NEUTRAL] And that's just.
[AGENT][NEUTRAL] All right, it looks like we received the claim [PII], process [PII], and the claim was denied. The reason for this denial is that outpatient benefits for the calendar year has been met.
[CUSTOMER][NEUTRAL] October.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Outpatient for the calendar year.
[CUSTOMER][NEUTRAL] Was [PII]. OK. Can I get the claim number?
[AGENT][NEUTRAL] Sure, the claim number is, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, that is 351-6062.
[CUSTOMER][NEUTRAL] But hey that's.
[CUSTOMER][NEUTRAL] OK. Outpatient for the calendar visit was met already, right?
[AGENT][NEUTRAL] The outpatient benefits for the calendar year has been in, correct.
[CUSTOMER][NEUTRAL] OK, I have one more patient. Could you please check that?
[AGENT][NEUTRAL] It's a different member or the same member, different date of service?
[CUSTOMER][NEUTRAL] Yeah, different, different number different data service mhm.
[AGENT][NEUTRAL] If I remember
[AGENT][NEUTRAL] OK, bear with me just a second. Let me finalize the note on this one and then we can move forward to the next one. OK, one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] OK, what's the next policy number?
[CUSTOMER][NEUTRAL] 02222305
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII], date of birth of [PII].
[AGENT][NEUTRAL] Thank you. And this is for dental or medical, Mr. [PII]?
[CUSTOMER][NEUTRAL] Medical, medical.
[AGENT][NEUTRAL] OK, let me pull the medical card. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yes, date of service is [PII].
[AGENT][NEUTRAL] What's the total charge amount?
[CUSTOMER][NEUTRAL] Total charge.
[CUSTOMER][NEUTRAL] $751 751 dollars.
[AGENT][NEUTRAL] OK, bear with me just a second. This one was processed twice.
[AGENT][NEUTRAL] Uh, let me pull the original.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so it looks like we received the claim [PII], processed [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the claim was denied. The reason for this denial is that the policy allows two emergency room benefits under the outpatient benefits. Policy benefits for individual maximum has been met.
[CUSTOMER][NEUTRAL] And.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] Policy only allowed 2 visits, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] This is the original claim, right? Original claim denied for reason is policy only allowed two visits. It was already exhausted.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Correct, that is correct.
[CUSTOMER][NEUTRAL] The claim number?
[AGENT][NEUTRAL] Claim number is 3353218.
[CUSTOMER][NEUTRAL] OK. Can I get the reference number for our conversation?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you would like, Mr. [PII]. Is there anything else I may help you with today?
[CUSTOMER][NEUTRAL] to.
[CUSTOMER][POSITIVE] No, that's all. Thank you so much for that.
[AGENT][POSITIVE] You're welcome and thank you for calling APL. Have a good afternoon, Mr. [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, one more, hello? Sorry, hello?
[AGENT][POSITIVE] Yes, go ahead, yes.
[CUSTOMER][NEUTRAL] Yeah, I think this one I'm looking for a pill one. This one already submitted a bill.
[AGENT][NEUTRAL] Nope.
[CUSTOMER][NEUTRAL] Yeah, I have, yeah, any appeal receive it, could you please check that.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, it looks like we received another claim which it was not an appeal, it was just another claim and it was denied as a duplicate. Do you need the information about that one?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] 01 moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I just the same.
[CUSTOMER][NEUTRAL] For this data service, submitted 2 claims.
[CUSTOMER][NEUTRAL] $82722 with the one is $751 and then another one is $1,071 claim.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Uh, for the $751 claim was denied.
[CUSTOMER][NEUTRAL] Due to duplicate, I submitted the two sets of medical records for this on [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, bear with me.
[CUSTOMER][NEUTRAL] The appeal submitted address is [PII].
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Uh, any appeal receive you, yeah.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mr. [PII], we're looking for a claim, um, for the appeal for the 751 or we're looking for the appeal for the other amount because you gave me two amounts. Which ones are you trying to look for the appeal on?
[CUSTOMER][NEUTRAL] for.
[CUSTOMER][NEUTRAL] Uh, 751. The claim denied is 751, correct? Yes.
[AGENT][NEUTRAL] For the 751.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] OK. CS 99.
[CUSTOMER][NEUTRAL] OK, yeah.
[AGENT][NEUTRAL] Or
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Hm
[AGENT][NEUTRAL] I, I don't see an appeal. I found another claim which it was duplicate. I found another claim that it was denied for the same reason, but I don't see any that are um an appeal. It is an appeal. Mhm.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][POSITIVE] OK. OK. Thank you so much for that. I wish you have. Any fax number?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and you have 180 days from the decision date to submit the appeal. Again, that's 180 days from the decision date to submit the appeals. Um, the fax number is [PII].
[CUSTOMER][NEUTRAL] For a.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][POSITIVE] OK. Thank you so much for that. Bye-bye.
[AGENT][NEUTRAL] Is there anything else I may help you with today, Mr. [PII]?
[CUSTOMER][POSITIVE] No, that's all. Thank you.
[AGENT][POSITIVE] Thank you for calling APO. Have a good day. Bye bye.
[CUSTOMER][NEUTRAL] OK bye bye.