AccountId: 011433970860
ContactId: 7ac3d19d-d47c-449b-ab44-83ad737f3668
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 921229 ms
Total Talk Time (AGENT): 276230 ms
Total Talk Time (CUSTOMER): 509055 ms
Interruptions: 15
Overall Sentiment: AGENT=0.8, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/08/7ac3d19d-d47c-449b-ab44-83ad737f3668_20250508T15:31_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello [PII], my name is [PII]. I'm calling here from provider's office.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hi, [PII], how are you doing today?
[CUSTOMER][NEUTRAL] I'm doing fine. How about you?
[AGENT][POSITIVE] I'm doing well. And how may I assist you today?
[CUSTOMER][NEUTRAL] So I have some claim that got denied. So can you help me with that claims?
[AGENT][POSITIVE] OK, I'll be more than happy to assist you with the claims and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, I have only one claim.
[AGENT][NEUTRAL] OK, and may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, it is [PII].
[AGENT][NEUTRAL] Thank you for that and the member's policy number?
[CUSTOMER][NEUTRAL] The name has been processed.
[CUSTOMER][NEUTRAL] Uh, the member ID is 01817282.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Member name is [PII]. 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 bill for the claim?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, date of service is [PII], and the total charge amount, just give me a moment. Let me check the total charge amount. It is $1800.
[CUSTOMER][NEUTRAL] OK, no problem. So can you share me the.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Uh, sorry, it is $1,892.
[AGENT][NEUTRAL] $1,892 OK.
[CUSTOMER][NEUTRAL] 779974.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] It is emergency professional services.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Can you move ahead with the another thing?
[AGENT][NEUTRAL] Alright, so I'm showing the claim was received on [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Just give me a moment. Uh, received on [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 35.
[CUSTOMER][NEUTRAL] After then?
[AGENT][NEUTRAL] The claim number is 355-0245.
[CUSTOMER][NEUTRAL] but I did.
[CUSTOMER][NEUTRAL] N C A S E.
[CUSTOMER][NEUTRAL] 682-800.
[AGENT][NEUTRAL] And on [PII], the claim was denied because the outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, can you repeat it once again?
[AGENT][NEUTRAL] The outpatient benefit.
[AGENT][NEUTRAL] For the calendar year?
[AGENT][NEUTRAL] Has been met.
[CUSTOMER][NEUTRAL] Outpatient benefit for this calendar year has been met, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And the benefit was in number of visits or in dollar value?
[AGENT][NEUTRAL] Dollar value, the max was $4000 for the year and it was used up by the time your your claim came in.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, just give me a moment. Max value is $4000 right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And how much the patient has made?
[AGENT][NEUTRAL] The patient has used all 4000, that's why we can't pay out on any more claims. They've used it all.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] How many visits does the patient have in uh annually?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] It's not that type of policy.
[CUSTOMER][NEUTRAL] OK. And what's the plan name of the member?
[AGENT][NEUTRAL] This is a Medlink supplemental gap insurance policy.
[CUSTOMER][NEUTRAL] Madeling.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Supplemental.
[CUSTOMER][NEUTRAL] Uh, can you repeat the name? Subliminal.
[AGENT][NEUTRAL] Get
[CUSTOMER][NEUTRAL] It's supplemental or subliminal?
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] Supplemental SUPP.
[CUSTOMER][NEUTRAL] OK. OK, thank you. Supplemental. It's meddling supplement gap. OK.
[AGENT][NEUTRAL] Subliminal gap.
[AGENT][NEUTRAL] Insurance policy.
[CUSTOMER][NEUTRAL] This is
[CUSTOMER][NEUTRAL] Insurance policy. OK, thank you. And uh.
[CUSTOMER][NEUTRAL] Is this claim process is in network or out of network?
[AGENT][NEUTRAL] There's no network, it's a secondary policy.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] OK, so can you give me the appeal mailing address?
[CUSTOMER][NEUTRAL] 000138867
[AGENT][NEUTRAL] Sure, our mailing address is [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] It's [PII] mailing address, OK.
[AGENT][NEUTRAL] That's the address that I'm giving you. Are you ready?
[CUSTOMER][POSITIVE] OK. Yes, yes, I'm ready.
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the zip code is [PII].
[AGENT][NEUTRAL] 24.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] It is [PII]. After that, it is [PII], right?
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] [PII]. Just give me a moment.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Our.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Can you give me the appeal filing limit?
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] Um, 180 days from the denial date.
[CUSTOMER][NEUTRAL] And call reference number?
[AGENT][NEUTRAL] There's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][POSITIVE] OK, OK. [PII], thank you. Thank you for your time. OK.
[AGENT][POSITIVE] You're very welcome. Was there anything?
[CUSTOMER][NEUTRAL] I have one more claim. You can help me with that also, right? I just check, I have one more claim. Can you help me with that?
[AGENT][NEUTRAL] Yes, hold on one moment, let me finish noting this one.
[CUSTOMER][NEUTRAL] in that.
[CUSTOMER][NEGATIVE] It is not right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, can you share me the call reference number for this one?
[CUSTOMER][NEUTRAL] I see.
[AGENT][NEUTRAL] And make sure on the appeal you put attention APL appeals department.
[CUSTOMER][NEUTRAL] 7
[CUSTOMER][POSITIVE] OK, no problem. OK, no problem.
[AGENT][NEUTRAL] Because it's the same address as claim.
[AGENT][POSITIVE] And I'm ready for the next member whenever you are.
[CUSTOMER][NEUTRAL] OK. So the next number ID is
[CUSTOMER][NEUTRAL] 01832190.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, the next member ID is 6824.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes. My name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that. And again, 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?
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Bye bye
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Uh, date of service is [PII] and the total charge amount was $1967.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yes, that is the letters [PII].
[AGENT][NEUTRAL] And would the um provider be the same on this claim or would it be different?
[CUSTOMER][NEUTRAL] Uh, just give me a moment. It is Sheridan Emergency physician Services.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Uh, patient name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Alright, so I'm showing we received the claim on [PII].
[CUSTOMER][NEUTRAL] 97.
[AGENT][NEUTRAL] The claim number is 355.
[CUSTOMER][NEUTRAL] 17.
[AGENT][NEUTRAL] 3410.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Because the maximum benefit payable for the date of service has been met.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Uh, can you repeat the denial once again?
[AGENT][NEUTRAL] The maximum
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Benefit
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Payable.
[CUSTOMER][NEUTRAL] OK, so, OK, and what the benefit was in dollar value or number of visits?
[AGENT][NEUTRAL] For this date of service?
[AGENT][NEUTRAL] Has been met.
[AGENT][NEUTRAL] Both, um, the max is $1000 per day. So for this date of service, the $1000 has already been used.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, just give me a moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, dollar value was $1000 right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And this and this claim was rendered from the same provider or different provider?
[AGENT][NEUTRAL] Same provider or different provider than who? The previous patient?
[CUSTOMER][NEUTRAL] Uh, no, for this member you are telling me for the same date of service, uh, $1000 has been met, right? So on the same day member is taking two services, right?
[AGENT][NEUTRAL] So you're asking me, is it, was it paid to you or to a different provider?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So you mean to say that the emergency services are not covered in the membership.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, no problem. Uh, can you tell me which plan the number I have.
[CUSTOMER][NEUTRAL] you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me take a look at these claims. Do you mind if I place you on just a brief hold?
[CUSTOMER][POSITIVE] Yeah, you can take your time, no problem.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 3621.
[AGENT][NEUTRAL] Yeah, but just because let me see if there was anything.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 2 978.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 3541344.
[AGENT][NEUTRAL] 3 wait, what was it? 3543.
[AGENT][NEUTRAL] it's supposed to be this.
[AGENT][NEUTRAL] This this one.
[AGENT][NEUTRAL] 35437.
[AGENT][NEUTRAL] 1356.
[AGENT][NEUTRAL] 3536.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I know, I'm almost done.
[AGENT][NEUTRAL] 734, that was the original.
[AGENT][NEUTRAL] JNOG.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes, I'm here.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for the wait. So yes, all the other claims that were paid for the same data service was a different provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] To the different provider, right?
[CUSTOMER][NEUTRAL] OK. Uh the plan name or the plan name of the member?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] This is a the same Medlink supplemental gap.
[CUSTOMER][NEUTRAL] OK. And uh your mailing address will be the same?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, so call reference number will also be the same, right?
[AGENT][NEUTRAL] Yes, that's correct. My name on today's date.
[CUSTOMER][POSITIVE] OK. So thank you, and thank you for your time. Thank you for helping me with these claims. OK.
[AGENT][POSITIVE] You're very welcome, [PII]. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, I only had 2 claims and you help me with that. Thank you. Thank you very much. OK. Have a good day. Bye-bye.
[AGENT][POSITIVE] You're very welcome and thanks for calling APL. Bye-bye.