AccountId: 011433970860
ContactId: 951f03b5-81a8-473c-b8fe-008967c77684
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 255100 ms
Total Talk Time (AGENT): 91308 ms
Total Talk Time (CUSTOMER): 78293 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/16/951f03b5-81a8-473c-b8fe-008967c77684_20250516T12:54_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] Hi, [PII], this is [PII] from University of Miami to check on the status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status, [PII]. And may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, it's uh [PII]. Extension is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] It's uh 01935548 M as in Mike, L as in Lima, number 8.
[AGENT][NEUTRAL] Thank you. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Just one.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] The member name is uh [PII], and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] It's [PII] and the bill amount is $117 even.
[AGENT][NEUTRAL] Thank you and all the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment while I locate the claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] University of Miami.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEUTRAL] Uh, can I get the time to.
[AGENT][NEUTRAL] Alright, so I'm showing we received the claim on [PII].
[CUSTOMER][NEUTRAL] the
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 356.
[AGENT][NEUTRAL] 0695.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And on [PII], the claim was denied because the outpatient max for the calendar year has been met.
[CUSTOMER][NEUTRAL] So they need for maximum benefit exhausted, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Mm it's for the receipt.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] It's for visit count, right?
[AGENT][NEGATIVE] The phone is breaking up. Say that one more time.
[CUSTOMER][NEUTRAL] Uh, may I know what is the exact reason for the denial?
[CUSTOMER][NEUTRAL] It's a dollar value or is it uh
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] So, as I stated, the max was met. So the maximum that they have in in in dollar amount has been used. There's no more money to use to the claims.
[CUSTOMER][NEUTRAL] OK. May I know what is the dollar value for the year?
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] $7350.
[CUSTOMER][NEGATIVE] OK. So they met all the amount and no benefit left, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So balance is members responsibility.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Balance $48.52 is the member responsibility, right?
[AGENT][NEUTRAL] Um, we don't determine patient responsibility because we're not the major medical, um, so it will be whatever your policies are for outstanding or remaining balances.
[CUSTOMER][POSITIVE] OK, thank you so much. And uh may I know the reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name and today's date, and again, that's [PII].
[CUSTOMER][POSITIVE] OK, [PII], thank you so much for your kindness and have a great day. Bye-bye.
[AGENT][POSITIVE] You also, thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.