AccountId: 011433970860
ContactId: 73738671-612d-43af-a9b8-8ab004feffeb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 400660 ms
Total Talk Time (AGENT): 131727 ms
Total Talk Time (CUSTOMER): 135701 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/10/73738671-612d-43af-a9b8-8ab004feffeb_20250610T20:01_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], this is [PII] and my last name [PII], calling from the provider's office to check on the claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to assist you with the claim status, [PII]. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Uh, only one.
[AGENT][NEUTRAL] Alright, and may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Yeah, the callback number is [PII]. It's a direct line.
[CUSTOMER][NEUTRAL] And the policy number 945137.
[AGENT][NEUTRAL] OK, hold on one moment, [PII]. The phone is going in and out. Can you repeat the phone number and the, the policy number? I, I can't hear anything.
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] The callback number is [PII]. It's a direct line.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the member ID is, and the policy number is 945137.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, and can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] 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 and the total bill for the claim?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII], the bill amount is $742.50.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] This is all one, OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the doc the provider's office on the claim?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, it's just a moment. She on George.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, the facility, the facility name.
[CUSTOMER][NEUTRAL] Uh, Duke University affiliated physicians.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I'm showing the claim was received on [PII].
[AGENT][NEUTRAL] The claim number is 350.
[AGENT][NEUTRAL] 8874.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because the calendar year policy maximum of 4 doctor visits per year has been met.
[CUSTOMER][NEUTRAL] OK, uh, is it applicable for the all procedure codes?
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So the whole claim has been denied for uh for the calendar year when the full service full visits are allowed for the member.
[AGENT][NEUTRAL] Correct, and they've exhausted all 4.
[CUSTOMER][NEUTRAL] And uh may I know uh what kind of uh services is allowed to meet the.
[CUSTOMER][NEUTRAL] Uh, the doctor for, so was it for you?
[AGENT][NEUTRAL] I'm sorry, I don't understand the question.
[CUSTOMER][NEUTRAL] Um, you stated that only 4 visits are allowed for the member, right?
[AGENT][NEUTRAL] Right, 4 physician office visits a year.
[CUSTOMER][NEUTRAL] For physician's office. OK. Uh, physician services, right, is it?
[AGENT][NEUTRAL] Yes, in-office physicians, specialist, there's 4 visits per calendar year.
[CUSTOMER][NEUTRAL] Oh, the place of service in office, uh, only 4 times allowed to build a member right? and uh.
[CUSTOMER][NEUTRAL] If the benefits has been exhausted, may I know, uh, if it comes under the member's responsibility?
[AGENT][NEUTRAL] So we don't determine patient responsibility. If there is a remaining balance, um, that would be up to you as the provider um to determine responsibility.
[CUSTOMER][NEUTRAL] OK, may I know if it's processed towards in network or out of network?
[AGENT][NEUTRAL] This is a supplemental gap insurance, so it's a secondary insurance. There's no network.
[CUSTOMER][NEUTRAL] Uh, may I know the supplements insurance name one more time, please?
[AGENT][NEUTRAL] Yes, this is a Medlink policy.
[CUSTOMER][NEUTRAL] Meddling policy, OK, uh, so you stated, uh, may I know the timely filing to submit the corrected claim?
[AGENT][NEGATIVE] Um, there's no timely filing for a corrected claim.
[CUSTOMER][NEUTRAL] OK, and may I know the mailing address to submit the correct account?
[AGENT][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh who do you help me with the call reference you know?
[AGENT][NEUTRAL] Yes, um, so there's no call reference number, but you can use my name in today's date. And again, that's [PII] initial to my last name is [PII].
[CUSTOMER][POSITIVE] OK, thank you so much for that [PII] and thank you so much for your assistance. Hope you have a great day bye bye.
[AGENT][POSITIVE] Thank you. You also, was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] No, that is all from my end and thank you so much for asking. Hope you have a great day bye bye.
[AGENT][POSITIVE] You also thanks for calling APL. Bye-bye.