AccountId: 011433970860
ContactId: 8c54e8b4-e726-4dbe-b16f-bb2ab9fa19e1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 333440 ms
Total Talk Time (AGENT): 75469 ms
Total Talk Time (CUSTOMER): 153547 ms
Interruptions: 0
Overall Sentiment: AGENT=1.2, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/01/8c54e8b4-e726-4dbe-b16f-bb2ab9fa19e1_20250501T13:56_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi [PII], good morning. I'm calling from the broker's office. I needed assistance in, uh, like clarifying what exactly was paid out on two claims for one of our members.
[AGENT][NEUTRAL] OK. And what was your name?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] And do you have a phone number I can get in case we get disconnected I can call you back?
[CUSTOMER][NEUTRAL] Uh yes, [PII].
[AGENT][NEUTRAL] And do you have a policy number?
[CUSTOMER][NEUTRAL] For the number, yes, give me just a moment.
[CUSTOMER][NEUTRAL] It's 250-1703.
[AGENT][NEUTRAL] Thank you, [PII]. Hold on one moment, please.
[AGENT][NEUTRAL] What's the patient's name?
[AGENT][NEUTRAL] The intern
[CUSTOMER][NEUTRAL] Uh, first name is [PII]. I'll spell it out.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And then the last name is [PII]
[AGENT][NEUTRAL] And his date of birth? Her date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, [PII]. And you are needing claim status?
[CUSTOMER][NEUTRAL] Uh, I just wanna clarify what exactly if, um, you know, the benefit itself was met. It's for a claim in 2024. I have
[CUSTOMER][NEUTRAL] A reference number for both claims.
[AGENT][NEUTRAL] OK, I can help you with that. Do you have a claim number or data service?
[CUSTOMER][NEUTRAL] Yes, the first date of service is [PII].
[CUSTOMER][NEUTRAL] And let me see if there's a claim number, yeah, the claim number is 3530027.
[AGENT][NEUTRAL] Yes, ma'am, the max was met on that claim.
[CUSTOMER][NEUTRAL] The max, OK, it was 3000, right?
[AGENT][NEUTRAL] Uh, let me check and see.
[CUSTOMER][NEUTRAL] Or did he use some of the benefit prior? That's what I wanted to confirm the exact amount met.
[CUSTOMER][NEUTRAL] Well, provided, and, and if possible, who was paid out to the member or the provider?
[AGENT][NEUTRAL] See for outpatient it's 3000, let's see.
[AGENT][NEUTRAL] It was paid to the provider.
[AGENT][NEUTRAL] And we paid $2,738.08.
[CUSTOMER][NEUTRAL] OK, and it was to the provider directly, OK.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] Perfect. And then.
[CUSTOMER][NEUTRAL] OK, let me look up the other one.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I believe for that same visit, there was a lab. Let me, I'm trying to pull up the information, sorry.
[AGENT][NEUTRAL] The same data service, yes, there was a lab.
[CUSTOMER][NEUTRAL] Yeah, there was a lab on the same day.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] We pay $9.92 on the lab.
[CUSTOMER][NEUTRAL] And that was also outpatient, classified as outpatient, correct? Outpatient, OK.
[AGENT][NEUTRAL] OK
[AGENT][POSITIVE] Correct. Mhm.
[CUSTOMER][NEGATIVE] OK, and then after that, there was no more availability for the outpatient benefit because it was already met.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] But was there any other claims that were submitted but maybe denied because of it?
[CUSTOMER][NEUTRAL] Or
[AGENT][NEGATIVE] There were 2 more claims that were denied.
[AGENT][NEUTRAL] To the insured as Max met for outpatients.
[CUSTOMER][NEUTRAL] And were they the same data service by chance?
[AGENT][NEUTRAL] Different data service.
[CUSTOMER][NEUTRAL] Or a different one, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] Would it, um, would you be able to provide those dates of service because I think that might be the issue that they're trying to submit claims but they're gonna be denied again if that, you know, that out of pocket was met.
[AGENT][NEUTRAL] [PII], and [PII].
[CUSTOMER][POSITIVE] And then [PII]. OK, perfect.
[CUSTOMER][POSITIVE] OK, I'll get back with the member and let them know. I appreciate all your help.
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] No, that was all.
[AGENT][POSITIVE] Thank you, [PII], for calling APL. You have a good day.
[CUSTOMER][POSITIVE] Thank you. You too.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] Bye.