AccountId: 011433970860
ContactId: 58c981af-9c8d-47c6-ae29-325b9d317442
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 620390 ms
Total Talk Time (AGENT): 256261 ms
Total Talk Time (CUSTOMER): 124903 ms
Interruptions: 0
Overall Sentiment: AGENT=1.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/18/58c981af-9c8d-47c6-ae29-325b9d317442_20250218T21:13_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[AGENT][POSITIVE] Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII] calling from provider's office.
[AGENT][POSITIVE] Hi [PII], how are you doing today?
[CUSTOMER][NEUTRAL] To check the claim status.
[CUSTOMER][POSITIVE] I'm good. How about you?
[AGENT][POSITIVE] I'm doing well, and I'll be more than happy to help you with the claim status. And [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Policy number. Just a moment.
[CUSTOMER][NEUTRAL] Uh, it's 02543700.
[AGENT][POSITIVE] Thank you and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] So [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Thank you. Hold on one moment. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Uh last name is [PII] and uh first name is [PII]
[AGENT][NEUTRAL] And the date of birth?
[CUSTOMER][NEUTRAL] Uh, date of birth is
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] Uh, data service is, uh,
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] The total bills?
[CUSTOMER][NEUTRAL] And the total bill is 9,999 and 10 cents.
[AGENT][NEUTRAL] Thank you, and all the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment while I locate the claim.
[AGENT][NEUTRAL] And I'm not showing a claim on file for [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] I'm not showing a claim on file for [PII].
[CUSTOMER][NEUTRAL] Uh, just a moment, please.
[CUSTOMER][NEUTRAL] So, I don't have a claim number. Yes.
[AGENT][NEUTRAL] OK, what's that claim number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, claim number is 3532265.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, so that's processed under a different policy number, policy number 2543696. Hold on one moment while I go to that policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, the claim was received on [PII] and on [PII], the claim was denied because the benefit maximum for the data service has been used.
[CUSTOMER][NEUTRAL] OK. So member have uh any dual plan activity?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Member have any dual plan?
[AGENT][NEUTRAL] A deal plan?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] What do you mean by a deal plan?
[CUSTOMER][NEUTRAL] What do you?
[AGENT][NEUTRAL] This is a hospital indemnity policy, it's a limited medical policy.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So actually, we have 2 member IDs here.
[AGENT][NEUTRAL] OK, what is it that you're trying to figure out? The, the policy number that you gave is no longer active. The policy number that I gave is the policy number that this claim was processed under. Are you asking me what the current or active policy number is?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, there's currently no active policy number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we have uh actually we have appealed for this, uh, claim.
[CUSTOMER][NEUTRAL] On [PII].
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] OK, I don't understand the question. What's the question?
[CUSTOMER][NEUTRAL] Uh, we have appeal on this claim.
[CUSTOMER][NEUTRAL] On [PII].
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] OK, so we received the claim on [PII].
[AGENT][NEUTRAL] Uh, yeah, it's the same. So the but this claim was denied because the calendar year max has been met.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] So, we have actually appealed on that, uh, date of the, the date.
[AGENT][NEUTRAL] OK, so the first claim was processed and denied on [PII].
[AGENT][NEUTRAL] The appeal was denied on [PII] because the max has been met, so we can't go over the max.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, could you please provide me a case ID?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, could you please provide the case ID?
[AGENT][NEUTRAL] Yes, it's 355-3373.
[CUSTOMER][NEUTRAL] OK. Uh, is it 3553373?
[AGENT][NEUTRAL] Yes, that's the 2nd claim that, that's the 2nd claim that you all sent in.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Or do you have any another level of appeal?
[AGENT][NEUTRAL] There would be no need to appeal. The max has been given. You can't pay out, you can't pay more than the maximum benefit and the max has already been paid.
[CUSTOMER][NEUTRAL] Can't
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh, how much is it made?
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] So the benefits that were used for this policy is the emergency room benefit and the um diagnostic testing benefit. I'm here. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So the diagnostic testing benefit is up to $100 for one test per calendar year.
[AGENT][NEUTRAL] And for the emergency room, the policy will pay up to $50.02 times per calendar year.
[AGENT][NEUTRAL] So we received this claim a total of 3 times. The first time that the claim was received, it was paid out on. So the other 2 times, it has to be denied, so there's no need for an appeal, it's been paid on.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK. How much is the payment amount?
[AGENT][NEUTRAL] The payment is $150.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] The, so the claim number that you provided was the, was one of the duplicates. The original claim number is 3526454.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] It was received on [PII] and on [PII], we paid out on the claim $150 100 dollars for the diagnos the diagnostic test which um was the max, and $50 remember it's two times per calendar year we applied one for your claim. So that was a total of $150.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh, could you please, uh, send a copy of uh determination letter?
[AGENT][NEUTRAL] No, we don't send providers termination letters for patients um policies.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, could you please provide me the call reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. The first initial and my last name is [PII].
[AGENT][NEUTRAL] And again, just for the call, all the information provided is a verification of benefits, not a guarantee of payment.
[AGENT][NEUTRAL] And [PII], was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh, sorry, could you please, uh, send me your street name?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, could you please spell your name?
[AGENT][NEUTRAL] Yes, my name is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. Thank you, [PII]. Thank you for the information.
[AGENT][POSITIVE] OK, you're very welcome. Thanks for calling APL. Have a great day.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[AGENT][POSITIVE] You're welcome. Bye bye.