AccountId: 011433970860
ContactId: 7796d3eb-1b79-4d69-a9c4-705aa18f4269
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 423200 ms
Total Talk Time (AGENT): 158752 ms
Total Talk Time (CUSTOMER): 161569 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/7796d3eb-1b79-4d69-a9c4-705aa18f4269_20250114T19:49_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling ATS Ms. [PII]. How may I help you?
[CUSTOMER][NEUTRAL] you
[CUSTOMER][NEUTRAL] Uh hello. Good afternoon. My name is [PII]. The first insult to my last name is [PII]. I'm calling from provider's office and working on a denials. How are you doing today?
[AGENT][POSITIVE] I'm doing well how are you?
[CUSTOMER][POSITIVE] I'm also doing good, thanks for asking.
[AGENT][NEUTRAL] You're very welcome, and [PII], may I have a good contact number in case we're disconnected and the member's policy number?
[CUSTOMER][NEUTRAL] Sure. The callback number will be [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Extension [PII]. The policy ID number will be D as in Delta 43,302,090.
[AGENT][NEUTRAL] Thank you. Do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Uh yes.
[AGENT][NEUTRAL] And on the card, do you see anywhere that says in hospital or outpatient policy cert number?
[CUSTOMER][NEUTRAL] They
[CUSTOMER][NEUTRAL] Mm mm mm mm mm.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] No, I'm not able to. I, I think it's a multi plan.
[AGENT][NEUTRAL] OK, what's the claim number that you received the denial?
[CUSTOMER][NEUTRAL] Uh, sure, just allow me a quick moment.
[AGENT][POSITIVE] Sure, take your time.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] The claim number will be 352.
[CUSTOMER][NEUTRAL] 9401.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII]. Date of birth will be [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Do you have a social for the member?
[CUSTOMER][NEUTRAL] Mm, I have to check.
[AGENT][NEUTRAL] Because with the claim number, it's.
[AGENT][NEUTRAL] The claim number is, it's an error claim, so I'm gonna have to do some research on this.
[CUSTOMER][NEUTRAL] OK, the social is not available.
[AGENT][NEUTRAL] And you said the first name is [PII]?
[CUSTOMER][NEUTRAL] The TV
[CUSTOMER][POSITIVE] That's right.
[AGENT][NEUTRAL] OK, and what type of policy is it?
[CUSTOMER][NEUTRAL] Uh, it's medical.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And this is a 90 degree benefit, right?
[AGENT][NEUTRAL] No, no, this is American Public Life.
[CUSTOMER][NEUTRAL] OK, let me check the OB. OK, yeah, we have received the, uh, EOB from the American public.
[AGENT][NEUTRAL] Can you verify Mr. [PII]'s date of birth?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] OK, here we go. So the policy number is 247.
[AGENT][NEUTRAL] 492 4.
[CUSTOMER][NEUTRAL] Yeah I don't know
[CUSTOMER][NEUTRAL] Uh yes.
[AGENT][NEUTRAL] And let me
[AGENT][NEUTRAL] Look for this claim. Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] V
[AGENT][NEUTRAL] What's the date of service for the claim? Actually, hold on, I think I just found it.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] S
[AGENT][NEUTRAL] This is for [PII]?
[CUSTOMER][POSITIVE] Mhm, that's right.
[AGENT][NEUTRAL] OK, and all the information provided is a verification of benefits, not a guarantee of payment. What questions did you have in reference to this claim?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEGATIVE] Uh, this claim was partially paid and for CPT code 93,000, we haven't received the payment.
[AGENT][NEUTRAL] Let me pull it up. Hold on one second.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I think.
[CUSTOMER][NEUTRAL] And when I can see the remark code, it says the maximum benefits payable for the state of service has been met.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hold on one second, I'm just trying to get to the right place now that I'm in the policy. You're fine.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] like
[AGENT][NEUTRAL] 01 in here.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] I'm just going to the benefits. Hold on one moment.
[CUSTOMER][POSITIVE] Sure, take your own time.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] And it was $75 OK.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] All right, so the outpatient sickness rider is up to $75 with a max of 5 visits per calendar year.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] So for this claim, the max of the $75 was applied, um.
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] So $75 will only get paid from the insurance company, not more than that.
[AGENT][NEUTRAL] Right, because for them, that's the maximum for their benefit is $75.
[AGENT][NEUTRAL] So we applied the
[CUSTOMER][NEUTRAL] Per day?
[AGENT][NEUTRAL] No, $75 with a max of 5 visits per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And for this CPT code, as I said, 9300, can we bill that to the patient?
[AGENT][NEUTRAL] Um, we don't determine patient responsibility. So, um, because we're not a major medical insurance company, so it, it depends on what your, um, what your policies are. If you can bill, uh, that would be up to you all, but in terms of the claim as a whole, yes, the max was applied.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, perfect. I got your point. Thank you so much for this information. Can you help me with the reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. Um and that's [PII], first [PII] to my last name is [PII].
[CUSTOMER][POSITIVE] OK, perfect. Thank you so much. Have a great rest of your day and take care. Bye-bye.
[AGENT][POSITIVE] Thank you, [PII]. You also, and thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Bye.