AccountId: 011433970860
ContactId: 78a0ff57-2736-41e9-94bd-78d046230053
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 861219 ms
Total Talk Time (AGENT): 178895 ms
Total Talk Time (CUSTOMER): 251248 ms
Interruptions: 2
Overall Sentiment: AGENT=1.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/17/78a0ff57-2736-41e9-94bd-78d046230053_20250617T20:26_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from the provider office to check up the claim status.
[AGENT][POSITIVE] OK, and I'll be more than happy to help you with the claim status, [PII], and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Yeah, I have only one claim.
[AGENT][NEUTRAL] Alright, and may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, the callback number is [PII] [PII].
[AGENT][NEUTRAL] Thank you. May I have the member's policy number?
[CUSTOMER][NEUTRAL] Yeah, the member's policy number is 02255682.
[CUSTOMER][NEUTRAL] And M for Marvel, L for Louise, E for an Elvish.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, the patient's, uh, last name is [PII] and the first name is [PII].
[AGENT][NEUTRAL] And the date of birth?
[CUSTOMER][NEUTRAL] And the date of birth is [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 bills for the claim?
[CUSTOMER][NEUTRAL] Uh, yeah, the date of service is [PII]. And the total.
[CUSTOMER][NEUTRAL] Charge amount is.
[CUSTOMER][NEUTRAL] Uh, 1 $1,316 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Providers office uh.
[AGENT][NEUTRAL] The facility name?
[CUSTOMER][NEUTRAL] Yes, yes. Just wait, I'm checking.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah, it's
[CUSTOMER][NEUTRAL] Baptist Health Surgery Center Kendall.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes, I'm here. Um, is there any other name or can you verify the tax ID?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] It's coming over as a different.
[CUSTOMER][NEUTRAL] Yeah, the
[CUSTOMER][NEUTRAL] Yeah, the tax ID is [PII].
[AGENT][POSITIVE] Thank you for that.
[CUSTOMER][NEUTRAL] And here it is, it is showing the another location ambulatory surgical center.
[AGENT][NEUTRAL] OK, so I'm showing that we received um the claim. Did you want the original claim or the last claim that we processed? It was received twice.
[CUSTOMER][NEUTRAL] Uh, the recent one I'm asking.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, which we have built on, yes, yes, tell me.
[AGENT][NEUTRAL] So I'm showing the claim was received on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Claim number is 3608834.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Because the outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] Sorry, why it has been denied?
[AGENT][NEUTRAL] The outpatient max has been met.
[CUSTOMER][POSITIVE] The operation Max has been met.
[AGENT][POSITIVE] Yes, the maximum benefits that they can use for outpatient.
[AGENT][POSITIVE] Expenses has been met. They used all of their funds.
[CUSTOMER][NEUTRAL] Oh, just wait. I'm checking in my system. Just be.
[CUSTOMER][NEUTRAL] Can you please tell me for uh for which he has been made, uh uh it it's units wise or dollar wise or visit wise?
[AGENT][NEUTRAL] It's dollar amount.
[AGENT][NEUTRAL] So the policy pays up to $1000 per calendar year. By the time your policy came in, the $1000 have been used.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] What.
[CUSTOMER][NEUTRAL] Hm, uh, let me check.
[CUSTOMER][NEUTRAL] Uh, yeah, the patient has uh the expenses up to the 1000, uh, for how much, uh, uh, for how much, uh, will you spend on this patient?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] So the $1000 is for the patient to use for the calendar year.
[CUSTOMER][NEUTRAL] He
[AGENT][NEUTRAL] By the time your claim came in to be processed, they had already used $1000 so there's no more money left to pay out on the claims for the year.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] January, they will restart.
[CUSTOMER][NEUTRAL] Uh, the, uh, when did the, uh, expenses has been expired?
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, this claim does not belong to your provider, so I can let you know that the benefits were exhausted.
[AGENT][NEUTRAL] Um, around [PII].
[CUSTOMER][NEUTRAL] Yeah, for which store it has been met for which date of service.
[AGENT][NEUTRAL] I cannot provide you with that information, sir. It's not your provider, so it's not your claim. We usually don't give this information to providers.
[AGENT][NEUTRAL] When your claim came in, the benefits were exhausted.
[CUSTOMER][NEUTRAL] 591.
[CUSTOMER][NEUTRAL] Why.
[CUSTOMER][NEUTRAL] Uh, uh, our dose is, uh, [PII].
[CUSTOMER][NEGATIVE] Uh, there is no benefits.
[CUSTOMER][NEUTRAL] For this, uh, just wait, I'm checking in my system.
[CUSTOMER][NEUTRAL] Yeah, can you?
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes, I'm here.
[CUSTOMER][NEUTRAL] Oh, yeah, just fine.
[CUSTOMER][NEUTRAL] Yeah, can you please check, uh, is there any other insurance for this patient?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Well, we're the secondary insurance, so the other insurance would be primary, um, which is UMR.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, do you have any member ID for the DMR insurance?
[AGENT][NEUTRAL] Um, no, you'd have to get that information from the insured. We just showed the name.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Uh, yeah, the primary insurance is Cigna and the secondary is commercial. uh, can we consider this?
[CUSTOMER][NEUTRAL] Uh, UMR as terriary.
[AGENT][NEUTRAL] Um, sir, we don't know of any other insurance. All we know is of UMR, which is primary, and our Metlink policy is second to it.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I follow it uh.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] But in my system it is showing as a signal, so that's why I got confused.
[AGENT][NEUTRAL] Um, they may have other, I can't really advise on that, sir. I'm not sure. They may have other insurance.
[AGENT][NEUTRAL] But our policy is not affiliated with it. We are only second to um UMR.
[CUSTOMER][NEUTRAL] Is it?
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, just wait.
[CUSTOMER][NEUTRAL] This.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] J for Alpha.
[CUSTOMER][NEUTRAL] India
[CUSTOMER][NEUTRAL] tangle over.
[CUSTOMER][NEUTRAL] uh yeah, OK, thank you. Can you please provide me the call reference number for this?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] Can you please spell your name?
[AGENT][NEUTRAL] Yes, my name is [PII]
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And today's date.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][POSITIVE] Yeah, OK. Thank you. Thank you for assisting me for today and have a nice day.
[AGENT][POSITIVE] You're very welcome, [PII]. Was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] No, I only have one claim.
[AGENT][POSITIVE] All right, thanks for calling APL. I hope you have a good day.
[CUSTOMER][NEUTRAL] Yeah. Bye.
[AGENT][NEUTRAL] Bye bye.