AccountId: 011433970860
ContactId: 7ef2b5ba-5527-4688-a7b6-436b4ebc5b2d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 418329 ms
Total Talk Time (AGENT): 181652 ms
Total Talk Time (CUSTOMER): 164264 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/12/7ef2b5ba-5527-4688-a7b6-436b4ebc5b2d_20250312T15:36_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], this is [PII] calling from provider's office to check up on a claim status. Also, this call is being recorded for quality and training purposes. Are you OK with that?
[AGENT][NEUTRAL] Yes, that's fine. And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Uh sure. It would be [PII]. And you said your name is [PII]. Is it [PII]?
[AGENT][NEUTRAL] Yes, and the first initial and my last name is [PII].
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] You're welcome. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Just one claim.
[AGENT][NEUTRAL] All right. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Sure. It would be 02345074.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure, it would be [PII] 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] Yeah, it's [PII] and the total charge amount is $500 even.
[CUSTOMER][NEGATIVE] I do have concern with the clinic.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, and what's the question?
[CUSTOMER][NEGATIVE] Actually, uh, it's about the denial, uh, actually you have paid $250 for this claim and, uh, the another uh remaining amount you have denied as maximum benefit met. So can you just help me with the denial like.
[CUSTOMER][NEUTRAL] Why you have paid just $250 as the patient's responsibility was $383.30.
[AGENT][NEUTRAL] So 200
[AGENT][NEUTRAL] So are we speaking of the claim for $383 or $500?
[CUSTOMER][NEUTRAL] 500.
[AGENT][NEUTRAL] So the claim that was a total of $500 claim number 3546934 was denied requesting the explanation of benefits from primary insurance, not because the max has been met.
[AGENT][NEUTRAL] So once we receive the explanation of benefits, we can continue processing this claim.
[CUSTOMER][POSITIVE] No, we have received payment as well from you.
[AGENT][NEUTRAL] The $250 is another claim. We're only speaking of the claim for the $500 correct?
[CUSTOMER][NEUTRAL] And the claim number
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, that's right, the claim number is 3555743.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] That is not the correct claim number. That claim number is for the total bill $383.30. The correct claim number is 3546934, and that totals $500. That claim was denied requesting the explanation of benefits from primary insurance. The other claim was not denied, it was paid.
[AGENT][NEUTRAL] So once we receive the explanation of benefits for this claim, we'll continue processing and provide the decision for you.
[CUSTOMER][NEUTRAL] Can you help me with the $383.30?
[CUSTOMER][NEUTRAL] Because we have received payment of $250.
[CUSTOMER][NEUTRAL] And the remaining amount, uh, here it shows.
[AGENT][NEUTRAL] OK, wait. So hold on, just so I can finish this. Are you done? Are are we complete with the claim you called in on?
[CUSTOMER][NEUTRAL] Not yet.
[AGENT][NEUTRAL] Because they're two different claims, so I don't want to loop them in together.
[AGENT][NEUTRAL] Did you have any other concerns for the $500 claim?
[CUSTOMER][NEGATIVE] Uh, no.
[AGENT][NEUTRAL] OK, so we're done with that one. OK, so what questions did you have in reference to this? Why was the 250 applied?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let's see, hold on one moment.
[AGENT][NEUTRAL] So the benefit for the outpatient um benefit per occurrence is $250. So the max was applied for this benefit.
[CUSTOMER][NEUTRAL] Uh, you mean to say you can only pay $250.
[CUSTOMER][NEUTRAL] For the claim or yearly?
[AGENT][NEUTRAL] The benefit is $250 per occurrence. Occurrence is anything with the related issue.
[AGENT][NEUTRAL] So since this is the first claim for this, the $250 was applied.
[AGENT][NEUTRAL] So that is the max for that benefit.
[CUSTOMER][NEUTRAL] Yeah, I just need to know, you said uh the $250 is applied only. So I just need to know uh like why because uh we have, uh, because the primary insurance has already processed as $383.30 and you said you have paid only $250. So the remaining amount is denied as maximum benefit met because you can only pay $250 right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Correct, that's, yes, that's what I'm explaining to you. Correct. The max was was paid to this claim.
[CUSTOMER][NEUTRAL] Yeah, so I just need to know, you can uh yearly pay $250 or per data service.
[AGENT][NEUTRAL] It's per occurrence. It's not per date of service or calendar year, it's per occurrence. Occurrence is anything of a.
[CUSTOMER][NEUTRAL] Uh, per procedure code.
[CUSTOMER][NEUTRAL] For service?
[AGENT][NEUTRAL] Occurrence is anything of a related service. So if it's for the knee, everything for the knee is one occurrence. If you then come in for the shoulder, that's another occurrence. So for this occurrence, we pay the max.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, sure. No problem. Thank you.
[CUSTOMER][POSITIVE] Thank you so much for your help. Uh, can you help me with the call reference number then?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date.
[CUSTOMER][POSITIVE] OK, sure, and uh thank you [PII]o much for your help.
[AGENT][POSITIVE] You're welcome, [PII] and thanks for calling [PII]. I hope you have a good day.
[CUSTOMER][POSITIVE] Bye bye take care.
[AGENT][NEUTRAL] Bye-bye.