AccountId: 011433970860
ContactId: 76ea3718-d97f-49ee-a836-27dd96120304
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 445239 ms
Total Talk Time (AGENT): 134604 ms
Total Talk Time (CUSTOMER): 130631 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/14/76ea3718-d97f-49ee-a836-27dd96120304_20250314T15:32_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII], and I'm calling for providers to check on additional information about the claim that has been denied. Please note this call will be monitor and recorded for quality and training purposes avoiding today.
[AGENT][POSITIVE] I'm good, thank you. How about you, Ms. [PII]?
[CUSTOMER][POSITIVE] Nice to hear that. I'm also good. And can I get your name one more time?
[AGENT][NEUTRAL] Sure, my name is [PII]. That's [PII]. Last [PII] is [PII]. And may I have a callback number just in case we get disconnected? You're welcome.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yes, I will call back number is [PII] and direct line.
[AGENT][NEUTRAL] You said [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Alright, and may I have the patient's policy number?
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] Patient's policy number?
[CUSTOMER][NEUTRAL] That is 250-1804.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] For this time, patient name is [PII], and date of birth is [PII].
[AGENT][NEUTRAL] OK. Thank you. What is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] For this claim, data services [PII], with that bill amount is
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] That is $120 even.
[AGENT][NEUTRAL] 120.
[CUSTOMER][POSITIVE] That's right.
[CUSTOMER][NEUTRAL] I
[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] And let's see.
[AGENT][NEUTRAL] All right, so it looks like it's been processed twice and I'm gonna pull the original one because the last one was processed as a duplicate. OK, one moment.
[CUSTOMER][NEUTRAL] OK. So for this claim,
[CUSTOMER][NEUTRAL] The claim number which is 3,567,540, that was done as a duplicate.
[AGENT][NEUTRAL] Yes, that is a duplicate, um, and we have an original one which is the one that I'm pulling right now.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So it, this was done as a duplicate on
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mm, let me go back to that one.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] One moment, 2540.
[AGENT][NEUTRAL] [PII] was the process as a duplicate. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] May I know the reason why it was done as a duplicate?
[AGENT][NEUTRAL] Yeah, that's why I'm waiting for the original one to pull up. OK, one moment.
[CUSTOMER][NEUTRAL] OK. Sure.
[AGENT][NEUTRAL] All right. So it looks like um the original one was processed [PII].
[AGENT][NEGATIVE] And it was denied stating that the calendar year policy maximum of 4 office visits per covered person has been exhausted.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just 1 2nd.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So that original claim.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] That was processed on
[CUSTOMER][NEUTRAL] Uh one second.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. And that original claim number is 3,530,620, is it right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So for this claim, that code which is 99213, has been denied for visit has been exceeded and you are allowed for office visits per calendar year.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. And may I know that when it was exceeded?
[AGENT][NEUTRAL] OK, we cannot release that information. I can only give you information pertaining your claim. When we receive your claim, the benefits have already been exhausted.
[CUSTOMER][NEUTRAL] So what this means, as per your guidelines, you won't provide additional information?
[AGENT][NEUTRAL] It means I can only give you information about your claim. I cannot release information about another claim or another provider.
[CUSTOMER][NEUTRAL] OK. So this claim was denied correctly, so you won't pay for the service.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Correct, it was denied stating that the maximum benefit has been exhausted for the office visits.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Uh, second.
[CUSTOMER][NEUTRAL] So what this means that outstanding amount is provided right now for the patient responsibility?
[AGENT][NEUTRAL] It's up to the provider's discretion. We don't have any contraction vomit. We are just a secondary policy. We're not the major medical.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Thank you. Can I get that call reference number for this number?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We don't have reference numbers you can use my name in today state if you would like to say.
[CUSTOMER][POSITIVE] Sure. Thank you, thank you so much for assisting me and have a wonderful day for you. Bye.
[AGENT][POSITIVE] You're welcome. You too. Thank you for calling ATM. Bye-bye.
[CUSTOMER][NEUTRAL] You don't.
[AGENT][POSITIVE] Thank you.