AccountId: 011433970860
ContactId: 84168a0e-9fe5-43e4-bc86-c2da2a93eba9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 452579 ms
Total Talk Time (AGENT): 154701 ms
Total Talk Time (CUSTOMER): 169593 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/16/84168a0e-9fe5-43e4-bc86-c2da2a93eba9_20250516T17:52_UTC.wav
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[AGENT][NEUTRAL] Good afternoon, thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hello, this is [PII]. Last term initial is [PII], and I'm calling from provider's office. Could you please help me with the claim?
[AGENT][NEUTRAL] Sure. May I have a callback number just in case we get disconnected, Mr. [PII]?
[CUSTOMER][NEUTRAL] Sure. Contact number is [PII] [PII].
[AGENT][NEUTRAL] OK, thank you. And may I have the name of the facility for my.
[CUSTOMER][NEUTRAL] Name of the facility is Delray Medical Center.
[AGENT][NEUTRAL] OK, and may I have the patient's policy number?
[CUSTOMER][NEUTRAL] That is OK.
[CUSTOMER][NEUTRAL] That is 018.
[CUSTOMER][NEUTRAL] 45704 M like Mary, L like Lima, number 8.
[AGENT][NEUTRAL] Thank you. May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] First name is [PII], and the last name is [PII], and the date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK. And what's the date of service and the amount of the claim, Mr. [PII]?
[CUSTOMER][NEUTRAL] That that is [PII] and the total amount on this claim is $4,0006 even.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] That's [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And for this claim, we do have submitted an appeal to the insurance.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And if you need that, uh, you need that, uh, I can provide you the appeal case number.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sorry, when the appeal was submitted? Appeal date.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Yeah, you can give me the date um and see if I, we received that appeal.
[CUSTOMER][NEUTRAL] Uh, that is on [PII].
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and this was an ER visit.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] One moment, I'm waiting on the system.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so it looks like we have not received that appeal. Um, the last submission was on [PII], processed [PII], and that was a duplicate claim. Um, the original claim.
[AGENT][NEUTRAL] Let me give you the information on that one.
[AGENT][NEUTRAL] Was received. Mhm.
[CUSTOMER][NEUTRAL] I know, I, I'm.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Actually, I'm asking for, when did you receive the appeal? I'm asking for the status of the appeal.
[AGENT][NEUTRAL] We have not.
[AGENT][NEGATIVE] We have not received an appeal.
[CUSTOMER][NEUTRAL] OK. There is no option on file?
[AGENT][NEUTRAL] Correct. There is no appeal on file.
[CUSTOMER][NEUTRAL] OK, got the point. So, could you please help me the reason for the denial purpose?
[CUSTOMER][NEUTRAL] Why this claim originally denied?
[AGENT][NEUTRAL] OK. The original denial was back in [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it was denied stating that oh patient benefits for the calendar year has been met.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. So, when was the last time the patient benefit was met?
[AGENT][NEUTRAL] We can now release that information.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes, um, Mr. [PII], can you hear me?
[CUSTOMER][NEUTRAL] Well, uh, yes, yes.
[AGENT][NEUTRAL] OK. Um, we cannot release that information because it does not pertain to your claim. I can only give you information about your claim.
[CUSTOMER][NEUTRAL] OK. Because I do believe that this claim was already uh denied. Uh, yeah, I do have the EOB and it was denied for the same reason that the patient benefit was already met. So, in that case, we need to document that when it was last met the date. So that
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] It's, it's a, uh, could you please tell me it's under our date of service or before our date of service, at least?
[AGENT][NEUTRAL] It's gonna be before your claim if it's already, if it's denied if your claim is denied is because your claim came last.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Got your point. So the patient benefit was already being met before we send this claim. OK, got your point. That's what I need to know.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Mhm. Yes.
[CUSTOMER][POSITIVE] OK. Thank you. Thank you for assisting me. Can I get a call number? So, what should we need to do in this case?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] We
[AGENT][NEUTRAL] It's up to the provider's discretion. The provider will need to make a decision.
[CUSTOMER][NEUTRAL] Uh, do we need to build this claim to the patient because the patient benefit was already been met, met as per the insurance?
[AGENT][NEUTRAL] It's up to the provider's discretion. We cannot tell you what to do with the claim. The only thing we can do is denied, um, which we did deny indicating he already used all his benefits, so you can just use this EOB to make a determination and the provider to know what to do with the claim, but we cannot tell you what to do with the claim.
[CUSTOMER][NEUTRAL] Oh OK.
[CUSTOMER][POSITIVE] Got it, got it. Thank you. Thank you for assisting me. Can I get a call number?
[AGENT][NEUTRAL] We don't have reference numbers you can use my name in today's date if you will.
[CUSTOMER][NEUTRAL] Oh, could you please spell your name?
[AGENT][NEUTRAL] Sure. That's [PII]. Last initial is [PII].
[CUSTOMER][NEUTRAL] OK, got it. Got it.
[CUSTOMER][POSITIVE] Thank you. Thank you for assisting.
[AGENT][NEUTRAL] Is there anything else I may help you today?
[CUSTOMER][POSITIVE] Uh, no, that will be all for much, sir. Thank you.
[AGENT][POSITIVE] You're welcome. Thank you for calling APL. Have a good day. Byebye.
[CUSTOMER][NEUTRAL] OK. Bye-bye.
[AGENT][NEUTRAL] Bye.