AccountId: 011433970860
ContactId: 85c4508f-c9d9-4a7f-8639-15a007f03446
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 308970 ms
Total Talk Time (AGENT): 131055 ms
Total Talk Time (CUSTOMER): 72805 ms
Interruptions: 2
Overall Sentiment: AGENT=0.9, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/02/85c4508f-c9d9-4a7f-8639-15a007f03446_20250102T20:59_UTC.wav
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[AGENT][NEUTRAL] Good afternoon, thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] at Prisma Health. I had a question about claim.
[AGENT][NEUTRAL] OK, are you needing status on a claim, [PII], or do you already have a claim number and you have additional questions?
[CUSTOMER][NEUTRAL] Yeah I, I have a claim number. I have a question.
[AGENT][NEUTRAL] OK, I can help you with that. And [PII], what is your callback number, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you and the member's policy number, please?
[CUSTOMER][NEUTRAL] With the D or the 02?
[AGENT][NEUTRAL] The 02 for APL.
[CUSTOMER][NEUTRAL] 02458169
[AGENT][NEUTRAL] OK, thank you. One moment.
[AGENT][NEUTRAL] And any information that I do provide for you today [PII] would be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Thank you. And the date of service and total bill amount, please?
[CUSTOMER][NEUTRAL] [PII] for 509.
[AGENT][NEUTRAL] And the claim number?
[CUSTOMER][NEUTRAL] 353-618-8
[AGENT][POSITIVE] Thank you one moment.
[AGENT][NEGATIVE] OK, so on the denial or I do say it was denied and the remarks states the maximum benefit for the outpatient sickness writer has been exhausted for the calendar year.
[CUSTOMER][NEUTRAL] OK. That's different than what we got.
[AGENT][NEUTRAL] Uh, this is not a major.
[AGENT][NEUTRAL] OK. What, what is your remark code?
[CUSTOMER][NEUTRAL] Our explanation benefit said uh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] We are awaiting information to confirm eligibility from a benefits and a card upon receipt of this information we continue processing your claim call benefits of that card.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so that was
[AGENT][NEUTRAL] Sure, OK, so at the time that we received the claim, that's what generated that. We were not able to confirm eligibility to review the claim, but that was done, and now the claim has been fully processed and denied with the remark that I just read. The maximum benefit for the outpatient sickness rider has been exhausted for the calendar year.
[AGENT][NEUTRAL] On this limited benefit plan, it's a max of 5 visits per calendar year.
[AGENT][NEUTRAL] And that had been reached.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] So, when was that process then?
[CUSTOMER][NEGATIVE] Or denied.
[AGENT][NEUTRAL] Um, this was [PII].
[AGENT][NEUTRAL] And has anyone ever given you, I was gonna say, [PII], do you have our website, our portal?
[CUSTOMER][NEUTRAL] Let me see if I can pull up the.
[CUSTOMER][NEUTRAL] I do. Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So with that same claim number, sure, absolutely. With that claim, same claim number, you should now.
[CUSTOMER][NEUTRAL] Let me see if I can pull it up real quick though.
[AGENT][NEUTRAL] Have access to the, to the remark that I just read.
[CUSTOMER][NEUTRAL] Claim number 353-6188.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Date of birth
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Looks like I might be able to print it.
[CUSTOMER][NEUTRAL] It's generating.
[AGENT][NEUTRAL] OK, OK, that's fine.
[AGENT][NEUTRAL] Make sure before we get off the call.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Outpatient significant mac OK.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][POSITIVE] So you do see, OK. All right, well, perfect. Well, is there anything else that I can help you with today?
[CUSTOMER][NEUTRAL] I do.
[CUSTOMER][POSITIVE] No, that's all I need. Thank you, [PII].
[AGENT][POSITIVE] Absolutely. You're very welcome, [PII]. Thank you again ma'am for calling APL and I hope you have a nice evening and a [PII].
[CUSTOMER][POSITIVE] You too, [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Bye-bye.