AccountId: 011433970860
ContactId: 5d0a78c2-2fbe-48a1-9f7c-6ba119ed299a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 711250 ms
Total Talk Time (AGENT): 238622 ms
Total Talk Time (CUSTOMER): 231837 ms
Interruptions: 1
Overall Sentiment: AGENT=-0.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/20/5d0a78c2-2fbe-48a1-9f7c-6ba119ed299a_20250520T21:09_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] Hi there this is [PII]. last to my. I is [PII]. I'm here for the claim information.
[AGENT][NEUTRAL] OK, sure, I can assist you with claims Mr. [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure. It is [PII].
[AGENT][NEUTRAL] Thank you. One moment, let me pull this information.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] May I have the policy number of the patient?
[CUSTOMER][NEUTRAL] Sure. It is D as decent 45401534.
[AGENT][NEUTRAL] OK, do you see a policy certificate number? It's gonna start with the 0 followed by 7 digits.
[CUSTOMER][NEUTRAL] Uh, just a second, uh, I have to take a look at the patient information for it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So the policy number for the member, just a second.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] So the policy number I have.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It is 02563602.
[AGENT][NEUTRAL] Mm, let me try that one moment.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Sure. It is for the member [PII] for the date of birth of [PII].
[AGENT][POSITIVE] OK, perfect. Thank you.
[AGENT][NEUTRAL] OK, and what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Sure, the first date of service I have is [PII] for the date amount of $250.
[AGENT][NEUTRAL] [PII] for 260.
[CUSTOMER][NEUTRAL] 250.
[AGENT][NEUTRAL] To be.
[AGENT][NEUTRAL] OK. Let me see if I can find this claim for you. For future, you can check claim status online through our website at [PII], and that's just optional.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Um, OK, let me pull this be one moment.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, I'm waiting on the UP.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, so it looks like it was tonight, um.
[AGENT][NEUTRAL] Waiting on the the reason, OK. One moment.
[AGENT][NEUTRAL] OK, so it was received on [PII] process [PII].
[AGENT][NEUTRAL] And this is a non-cover service benefit maximum for the date of service has been met.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So, you said for the data service benefits are, are maximum.
[AGENT][NEGATIVE] Yes, I've been exhausted.
[CUSTOMER][NEUTRAL] So, in your system, is there any other claim on the same date of service because in our system, there is only a single claim for the date of service.
[AGENT][NEUTRAL] We get many claims for any provider of service for any facility. So, um, by the time we got your claim, she already assessed her benefit.
[CUSTOMER][NEUTRAL] So, can you please confirm, uh, like for how many office visits can be billed uh for the member plan in a month?
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] All right, and this is not a guarantee of payment, just a verification of coverage. We cover 150 per day, maximum of 4 days per cover person per calendar year.
[CUSTOMER][NEUTRAL] Uh, you said in a calendar year the office has been covered 4 times.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Only 4 times.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And is there any like uh
[CUSTOMER][NEUTRAL] A gap between if uh insurance covering the one office visit on the date of service of [PII], then if there is any gap that for how many gaps or for how many days after the insurance will uh process the next office visit.
[AGENT][NEUTRAL] I'm not really understanding your question.
[AGENT][NEUTRAL] Mr. [PII].
[CUSTOMER][NEUTRAL] You said that there are 4 frequency or approved annually for the office visit for the member plan, so I'm just asking, is there any time frame and between these 4 times like we can build uh once in a 3 month or something else like this.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, it's one, it's gonna be 4 days, but it's the benefit is 150 per day. So we pay up to 4 days. It could be consecutive or it could be like days apart, weeks a car apart, months apart. There's not like a, you know.
[AGENT][NEUTRAL] A time frame that you need to send the claim for the office visit is 4 per year. Now the benefit is 150 per day, so we've received more than one claim for that date of service, then, uh, and she already exhausted the benefit like this one, then the maximum has been exhausted, so there's no more to pay for that day.
[CUSTOMER][NEUTRAL] So for this data service there is no other claim, and can you please confirm the diagnosis condition that applied on the claim is covered or not because it looks like the diagnosis we submitted submitted or not covered for the code.
[AGENT][NEUTRAL] They didn't know it's not due to the cold.
[AGENT][NEGATIVE] At all.
[AGENT][NEUTRAL] The denial is benefit maximum for the date of service has been met.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] So I have one more data service for you for the the number.
[AGENT][NEGATIVE] Is it for a different member you said? You're breaking up.
[CUSTOMER][NEUTRAL] Yes, it is for the same member.
[AGENT][NEUTRAL] For the same member. OK, what is the next date of service?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So the next state of service I have for you is like [PII] for the bill amount of $3160.
[AGENT][NEUTRAL] 3160, and you said date of service, [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] What is the procedure code?
[CUSTOMER][NEUTRAL] So there are just 18 procedure codes on file for the claim. The first procedure code that got paid is $99215 for $150 while other all 17 codes were denied. So I just want to know the denial reason for all the other codes that got denied.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] We only pay 150 per day.
[AGENT][POSITIVE] The maximum benefit.
[CUSTOMER][NEUTRAL] We are.
[CUSTOMER][NEUTRAL] Yes, you said it got paid on the date.
[AGENT][NEUTRAL] The maxim
[CUSTOMER][NEUTRAL] So for the previous data of service for which like uh [PII], do you have reference for the member that uh for that date of service you have paid uh any claim or like uh any other facility claim.
[AGENT][NEUTRAL] OK, um, Mr. [PII], I can only give you information about your claim, OK? So for date of service [PII], this was your claim. You submitted this claim. We pay the 150 for the 99215. The 150 is the maximum benefit and the rest is denied because that is the maximum we don't pay more than 150 per day, OK?
[AGENT][NEGATIVE] On the [PII], on the [PII], we received more than one claim from more than one provider.
[AGENT][NEUTRAL] Your claim was denied because the maximum benefit has been exhausted.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yes, I'm not asking for the claim information, but you can tell us the provider name or the facility name which is the outpatient facility for reference.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] No, no, no. We cannot give you information that is not your claim. We cannot give you information about another provider.
[AGENT][NEGATIVE] That's not something we can do.
[CUSTOMER][NEUTRAL] Got it. Can you please confirm the member's plan type, like what kind of plan type it is and the plan full name?
[AGENT][NEUTRAL] This is a limited hospital indemnity plan.
[CUSTOMER][NEUTRAL] Limited hospitals and
[AGENT][NEUTRAL] Limited hospital indemnity plan.
[CUSTOMER][NEGATIVE] You said damn.
[AGENT][NEUTRAL] Indemnity, I N D E M N I T Y indemnity.
[CUSTOMER][NEUTRAL] Got it. Can you please spell out your first name and last name for referencing?
[AGENT][NEUTRAL] My name is [PII]. That's [PII] [PII]. Last initial [PII].
[CUSTOMER][NEUTRAL] And is there any call reference number for today?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name and today's date if you would like, Mr. [PII]. Is there anything else I may help you with today?
[CUSTOMER][POSITIVE] Have a nice day bye bye.
[AGENT][POSITIVE] OK, you as well and thank you for calling APL. Bye-bye, Mr. [PII].