AccountId: 011433970860
ContactId: 5b56abb4-0039-493e-862c-ebfa43ae64d3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 377040 ms
Total Talk Time (AGENT): 134188 ms
Total Talk Time (CUSTOMER): 134230 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/21/5b56abb4-0039-493e-862c-ebfa43ae64d3_20250521T17:56_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah, hi. My name is [PII] calling from provider's office to check claim status.
[AGENT][NEUTRAL] May I have your name again?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And your callback number please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you [PII]. What is your policy number?
[CUSTOMER][NEUTRAL] OK. So the policy number is going to be 02415, 02451577 M as in Mike L as in Lima 8.
[AGENT][NEUTRAL] OK, if you could repeat that please.
[CUSTOMER][NEUTRAL] 02451577 M as in Mike, L as in Lima, 8.
[AGENT][POSITIVE] OK, thank you very much.
[AGENT][NEUTRAL] Verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] [PII], and date of birth [PII].
[AGENT][NEUTRAL] OK, thank you very much for that verification. And again you're calling for claim status. I can help you with this. You can check claim status also by using our secure portal at [PII], and you'll be able to obtain an EOB from that website as well. Uh, [PII], what is that date of service and the total charge amount please? Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So it's, yeah, so it's [PII] with the total charges of $55,504.14.
[AGENT][NEUTRAL] OK, that was [PII] and the total charge again please?
[CUSTOMER][NEUTRAL] So, it's $55,504.14. So, I have you be in front of me. I have a question whenever you're ready.
[AGENT][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What is that claim number?
[CUSTOMER][NEUTRAL] 359-779-9
[AGENT][POSITIVE] Thank you so much. Let me get that pulled up one moment, I'll be able to assist you.
[AGENT][NEUTRAL] OK, I have that pulled up and you have a question in regards to the EOB. I can assist you with that question.
[CUSTOMER][NEUTRAL] So as I'm seeing that here, uh, uh, there is no denial except uh OA 45, maximum allowable or uh charges exceeded fee schedule means is it primary paid more than secondary allowed amount?
[AGENT][NEUTRAL] I'm sorry, the denial for claim number 3597799 states that the inpatient benefit for this calendar year has been met.
[CUSTOMER][NEUTRAL] Uh, one second, ma'am.
[AGENT][NEUTRAL] Of
[CUSTOMER][NEUTRAL] OK. So can you please repeat the denial reason one more time?
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] Inpatient benefit for this calendar year has been met.
[CUSTOMER][NEUTRAL] OK, 1 2nd.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, is it in terms of amount or visits?
[AGENT][NEUTRAL] It is in
[CUSTOMER][NEUTRAL] Or units.
[AGENT][NEUTRAL] It's in terms of amount per year that was allotted.
[CUSTOMER][NEUTRAL] Uh, what is that amount per, like allowed per year?
[AGENT][NEUTRAL] OK, one moment, let me get that information for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Please note verification of benefits provided in the not guarantee payment. The max was $2000 for inpatient benefits for the calendar year.
[CUSTOMER][NEUTRAL] For impatient.
[CUSTOMER][NEUTRAL] So, may I know when was that amount met?
[AGENT][NEUTRAL] Um, it was met prior to the receipt of the claim that you're calling in reference to?
[CUSTOMER][NEUTRAL] I didn't get that, sorry.
[AGENT][NEUTRAL] OK, the amount was maxed out prior to.
[AGENT][NEUTRAL] The receipt of the claim that you're calling in reference to.
[CUSTOMER][NEUTRAL] Uh, ma'am, can you please provide me the exact date?
[AGENT][NEUTRAL] A claim was processed on [PII] that maxed out benefits.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Claim processed on [PII], so prior to [PII] only those uh benefits met, right, by the patient.
[AGENT][NEUTRAL] A claim processed on [PII], a claim processed on [PII], and those benefits max out the inpatient max.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So, can we bill this to member?
[AGENT][NEUTRAL] APL does not determine patients responsibility. I cannot advise that, [PII].
[CUSTOMER][NEUTRAL] Sorry
[CUSTOMER][NEUTRAL] So, is it on the patient plan only, right? That amount has been met for the calendar year?
[AGENT][NEUTRAL] Under the patient's plan, the inpatient max has been met for this calendar year.
[CUSTOMER][NEUTRAL] OK. So you're not uh pay for the service, right?
[AGENT][NEUTRAL] The allowed amount of $2000 has already been met.
[AGENT][NEUTRAL] For the calendar year for inpatient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, can I get the call reference number?
[AGENT][NEUTRAL] We do not provide call reference numbers. [PII]. You can use my name [PII] last initial L like [PII], and today's date. Anything else I can assist you with?
[CUSTOMER][POSITIVE] No, thanks. That's it. Have a nice day. Bye-bye.
[AGENT][POSITIVE] Thank you for calling AP I'll take care. Bye bye.