AccountId: 011433970860
ContactId: 511bb0eb-c8be-4611-b96d-3a32149d0c8c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 415559 ms
Total Talk Time (AGENT): 130170 ms
Total Talk Time (CUSTOMER): 99507 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/28/511bb0eb-c8be-4611-b96d-3a32149d0c8c_20250128T19:21_UTC.wav
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[AGENT][POSITIVE] Good afternoon, thank you for calling APL. This is [PII]. How may I assist you?
[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, sir. My name is [PII]. I have a representative calling from LES Dermatology to check on claim status. Could you please help me with that?
[AGENT][NEUTRAL] Sure, I can assist you with claim status, Ms. [PII]. And may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yeah, it's [PII] and it's a direct line.
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yeah. The policy number is 02369696 M as in Mike L as in Lima 8.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] It's [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] holder, may I have the date of service and the amount of the claims?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, date of service is [PII]. The bill amount is $523.48.
[AGENT][NEUTRAL] OK, so I'm looking for a claim for [PII], amount $523.48. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, do you mind holding for me for a minute? I'm gonna check on this claim.
[CUSTOMER][NEUTRAL] Yeah, 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 Ms. [PII]. OK, we processed the claim on [PII] and the claim was denied. Um, the reason for this denial, um, and there's several denials, but the, the code 99204 was denied because office visits are not covered by the policy. Um, the rest of the codes were denied because the outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] OK. 99204. The officers it has been not covered as per the policy. OK. The remaining cards weight has been denied.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Because uh outpatient benefits for the calendar year has been met.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I've been met.
[AGENT][NEUTRAL] outpatient benefits for the calendar year has been met, so they exhausted the benefits for outpatient service for the calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For the calendar year, uh, may I know how, how many visits, it, it is made by visit or uh?
[AGENT][NEUTRAL] Amount.
[CUSTOMER][NEUTRAL] Unit amount. OK, can I get the for how much they have as per the policy?
[AGENT][NEUTRAL] Amount.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, let me check that for you one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Outpatient maximum is 2000 per person per calendar year.
[CUSTOMER][NEUTRAL] How much?
[AGENT][NEUTRAL] 2000 per cover person per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. And when they have met the 2000? Do you have the date?
[AGENT][NEUTRAL] Oh, we cannot release that information. I can only let you know the information on your claim and based on the information on your claim, when we process the claim, the benefit maximum has been exhausting.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, got it. Can I have the call reference number?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will. Do you need the spelling of my name or any other information?
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Yeah, could you please spell that for me?
[AGENT][NEUTRAL] Sure. My name is [PII]. That's initial is [PII].
[CUSTOMER][POSITIVE] OK, thank you so much for helping me on this one and have a great day and bye for now.
[AGENT][NEUTRAL] OK. You as well. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Yeah, one moment.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] OK, got it. Thank you so much and uh yeah, that's all. Have a great day and bye for now.
[AGENT][POSITIVE] OK, thank you for calling EPO. Have a good day. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.