AccountId: 011433970860
ContactId: 5bc894a7-762d-4bd3-8231-37b27caaccbe
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 562799 ms
Total Talk Time (AGENT): 240604 ms
Total Talk Time (CUSTOMER): 120299 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/27/5bc894a7-762d-4bd3-8231-37b27caaccbe_20250127T15:51_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, I'm [PII] calling from provider's office to check up on the claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status and for my notes, can you spell your first name for me please and provide a good contact number?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] Uh, my name was, it's [PII]. Uh, and my callback number was uh
[CUSTOMER][NEUTRAL] [PII]. Uh, meanwhile, I missed your name. Could you please spell your name for me?
[AGENT][NEUTRAL] Yes, my name is [PII].
[CUSTOMER][NEUTRAL] And
[CUSTOMER][POSITIVE] Yeah, thank you so much for that. Uh.
[AGENT][NEUTRAL] You're welcome, [PII]. How many um claims do you have in total today?
[CUSTOMER][NEUTRAL] Uh, just a moment, uh.
[CUSTOMER][NEUTRAL] Yeah, I have only one claim for this, uh.
[AGENT][NEUTRAL] All right, and may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] It's 1221549 M as Mike, L as Lima 8.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah. Uh my first name was uh [PII]. It's [PII] and last name [PII]
[CUSTOMER][NEUTRAL] And the date of birth was uh [PII].
[AGENT][NEUTRAL] OK, wait a minute.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] So [PII], and the, what's [PII]'s date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you for that. And all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you like me to check on?
[CUSTOMER][NEUTRAL] Yeah. It's [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes, right.
[AGENT][NEUTRAL] And may I have the total bill?
[CUSTOMER][NEUTRAL] And may
[CUSTOMER][NEUTRAL] Yes, it's $355 even.
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment while I locate the claim.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah, it's Holy Cross Hospital Medical.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] So I'm showing the claim was received on [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] The claim number is 354.
[AGENT][NEUTRAL] 0531.
[AGENT][NEUTRAL] And on [PII], the claim was denied. Hold on one moment, I'm getting that reason for you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Alright, so from the explanation of benefits that we received, it's showing that the
[CUSTOMER][NEUTRAL] All right, so from the explanation
[AGENT][NEUTRAL] Major medical, um, didn't provide any benefits. So if you have a, um, hold on one moment. If you have an explanation of benefits that shows where primary did apply,
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] If you
[AGENT][NEUTRAL] Just, uh, submit that.
[CUSTOMER][NEUTRAL] Yeah, no, we
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Yeah. Uh, we have already, uh, submitted the explanation benefits on, uh, through fax on, uh.
[CUSTOMER][NEUTRAL] Uh, [PII]. Could you please check it?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] OK, so the reprocessed claim was received on [PII]?
[CUSTOMER][NEUTRAL] the process
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And the claim number is 355.
[AGENT][NEUTRAL] 5730.
[AGENT][NEUTRAL] And on [PII], we paid out to the provider a single check.
[AGENT][NEUTRAL] In the amount of $98.59.
[CUSTOMER][NEUTRAL] Uh, what is the allowed account?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For outpatient, the benefit is up to $4000 per calendar year.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Are you wanting to know why the remaining balance was not paid? Is that why you're asking that?
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] So let me take a look and see for the other um codes what happened. Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] So for code 3079F and 3075F.
[AGENT][NEGATIVE] They were not paid because the policy does not provide a benefit for services in which no charges were incurred.
[CUSTOMER][NEUTRAL] Not
[AGENT][NEUTRAL] The only charges was the $98.59.
[CUSTOMER][NEUTRAL] only charge
[AGENT][NEUTRAL] For 99214 and that was paid in full.
[CUSTOMER][NEUTRAL] OK. How much is the amount uh uh still the patient has met?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] They have $363.31 left to use for 2024.
[CUSTOMER][NEUTRAL] 3
[AGENT][POSITIVE] Oh, actually, hold on one second, I'm sorry.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] This is [PII].
[AGENT][NEUTRAL] She has $2,921.41 left for 2024.
[CUSTOMER][NEUTRAL] 21
[CUSTOMER][NEUTRAL] Uh, sorry, it's sir, 2000?
[AGENT][NEUTRAL] $2,921.41.
[CUSTOMER][NEUTRAL] Uh, what was the allowed amount for this claim?
[AGENT][NEUTRAL] Sir, the the amount for the calendar year is $4000.
[AGENT][NEUTRAL] Of that, she has $2,921.41 left for 2024.
[AGENT][NEUTRAL] The reason the other two codes were not was not paid is because the explanation of benefits did not list a charge.
[CUSTOMER][NEUTRAL] Hello
[CUSTOMER][NEUTRAL] Uh, sorry, I did not get your point. Could you please repeat one second for me?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] I did not understand your point. Uh, could you please repeat one second for me?
[AGENT][NEUTRAL] On the claim that you're calling in reference to?
[AGENT][NEUTRAL] The total
[AGENT][NEUTRAL] That was charged with $98.59. That is the amount that we paid on this claim.
[AGENT][NEGATIVE] The other two codes on the explanation of benefits, it showed 0. There was no charge there. So we cannot pay out on a code with no charge.
[CUSTOMER][POSITIVE] Oh, OK. Thank you so much for that. Uh, when was, uh, paid, uh, when the amount has paid?
[CUSTOMER][NEUTRAL] that
[AGENT][NEUTRAL] We issued the check on [PII].
[AGENT][NEUTRAL] So last Friday, so you should be receiving that shortly. It's coming from [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Uh, OK. Thank you so much for the information. Uh.
[AGENT][POSITIVE] You're very welcome. Was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] OK, I'm done with the information.
[CUSTOMER][NEUTRAL] Uh, nothing. Uh, could you please forward me the call reference numbe[PII] for this?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. So that's [PII]
[CUSTOMER][NEUTRAL] What
[CUSTOMER][POSITIVE] No problem
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] The first initial of my last name is [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And then today's date.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yeah, thank you so much for the information. Have a nice day. Bye-bye.
[AGENT][POSITIVE] You also, thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Yeah.