AccountId: 011433970860
ContactId: 98052375-bcd0-4b64-8c19-d2df730c3af5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 636270 ms
Total Talk Time (AGENT): 227478 ms
Total Talk Time (CUSTOMER): 249369 ms
Interruptions: 13
Overall Sentiment: AGENT=0.8, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/17/98052375-bcd0-4b64-8c19-d2df730c3af5_20250617T14:04_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, good morning. My name is [PII], and I'm checking claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status [PII]. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] I have just one claim to check.
[AGENT][NEUTRAL] Alright, may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, contact number is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] 02042058 M as in Mary L as in Lima 8.
[AGENT][NEUTRAL] I'm sorry, can you repeat the policy number, please? It's like a, like a background noise is covering you.
[CUSTOMER][NEUTRAL] Can you repeat the
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, sorry about that. Yeah, the policy number is 02042058 M as in Mike L as in Lima 8.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Thank you, can you give me your phone number
[CUSTOMER][NEUTRAL] And the name and date of birth?
[CUSTOMER][NEUTRAL] Member's name is [PII].
[CUSTOMER][NEUTRAL] Date of birth, [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 bill for the claim?
[CUSTOMER][POSITIVE] Thank you for that, and all the information provided is the verification of benefits that a guarantee and statements. I like to have.
[CUSTOMER][NEUTRAL] Date of service.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Bill amount $705.72.
[AGENT][NEUTRAL] And that was $705.72?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Can you give her the name of the Nicholas Children's Hospital.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] I you.
[CUSTOMER][POSITIVE] Not a problem, you take your time.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What?
[AGENT][NEUTRAL] So then why are we asking for the explanation of benefits?
[AGENT][NEUTRAL] If
[AGENT][NEUTRAL] What?
[AGENT][NEUTRAL] Is it the same thing or it's the same code.
[AGENT][NEUTRAL] Wait a minute, say what now?
[AGENT][NEUTRAL] What is it? 7, I mean 847, OK.
[AGENT][NEUTRAL] 347.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then 907.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So then how does it change?
[AGENT][NEUTRAL] Why do we need the explanation of benefits now?
[AGENT][NEGATIVE] I'm giving the original because that don't make sense.
[AGENT][NEUTRAL] Why do we need the explanation of benefits um.
[AGENT][NEUTRAL] Well, unless the first one was wrong.
[AGENT][NEUTRAL] Oh Lord.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh wait, it's only 24.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK, so that's true.
[AGENT][POSITIVE] Alrighty then
[AGENT][NEUTRAL] Hello A.
[CUSTOMER][NEUTRAL] Yes, sorry.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. Um, so the claim was received, um, 3 times, but did you want the original claim?
[CUSTOMER][NEUTRAL] You
[CUSTOMER][POSITIVE] Not a problem.
[CUSTOMER][NEUTRAL] So why the status remains the same for all.
[AGENT][NEUTRAL] No, the second one was denied as a duplicate, but basically it was denied because the outpatient max was met by the time your claim came in. Did you need the dates and claim number?
[CUSTOMER][NEUTRAL] Yeah, the second one was the design as the case but basically it was designed because the outpatient.
[CUSTOMER][NEUTRAL] But you need to.
[CUSTOMER][NEUTRAL] Uh yes, please.
[AGENT][NEUTRAL] OK. Um, so we received it on [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] We processed it on [PII].
[CUSTOMER][NEUTRAL] that there
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the claim number is 347.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] is 347.
[AGENT][NEUTRAL] 684 7.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 57
[AGENT][NEGATIVE] And um it was denied because the outpatient benefit for the calendar year was met.
[CUSTOMER][NEUTRAL] And um it was the that you have they should be the picture in the calendar here.
[CUSTOMER][NEGATIVE] And denied for
[AGENT][NEUTRAL] Outpatient benefit.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For the calendar year?
[CUSTOMER][NEUTRAL] The calendar here
[AGENT][NEUTRAL] has been met.
[CUSTOMER][NEUTRAL] So, uh,
[CUSTOMER][NEUTRAL] If you don't mind, could you please verify like how many services are allowed per calendar year?
[AGENT][NEUTRAL] So this isn't that type of benefit, um.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The dollar amount is $1500 per year, and this is saying by the time your claim came in, they used the full $1500 so there was no more money to pay out.
[CUSTOMER][NEUTRAL] $1 amount is 1000 not $1.
[CUSTOMER][POSITIVE] They like that.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Oh, so this was in terms, this was in terms of dollar amount, not the visit date.
[AGENT][POSITIVE] They use all their benefits.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And when was the last service, uh, it was, you know, uh, paid for the service.
[AGENT][NEUTRAL] Are you asking when the benefit ma?
[CUSTOMER][NEUTRAL] Are you asking what the benefit that? Yeah.
[CUSTOMER][NEUTRAL] When was the last service it was made.
[AGENT][NEUTRAL] Um, I can let you know the date that the claim processed.
[CUSTOMER][NEUTRAL] So the date that your claim.
[AGENT][NEUTRAL] Let me see if it's your provider's claim. Hold on one moment. What's your tax ID?
[CUSTOMER][NEUTRAL] like
[CUSTOMER][NEUTRAL] What's your tax ID?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Alright, so, um, claim number 3461601.
[CUSTOMER][NEUTRAL] So, um, claim number 3461601.
[AGENT][NEGATIVE] Exhausted all of the outpatient benefits, that was the remainder that she had of the $1500 the $55 that we paid.
[CUSTOMER][POSITIVE] Exactly.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] So I that was the last claim, uh, this is the last claim number it was paid right for the remaining 1500. It was made under the claim number 3461601.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] So for the whole year of [PII], she has the $1500 to use. The last claim that was processed that exhausted those funds is the claim number I just gave you. $55 was applied to that claim, that's all she had left for the of the $1500.
[CUSTOMER][NEUTRAL] So for the whole year of [PII], she has the $1500.
[CUSTOMER][POSITIVE] I like that like I just take you.
[CUSTOMER][NEUTRAL] apply to that claim. That's all she has left for the of the.
[CUSTOMER][NEUTRAL] OK. And if you don't mind for this claim number, uh, we will be able to verify the date of service.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] 2
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So then in that case, the account balance like the remaining balance is going to be a patient responsibility now, right?
[AGENT][NEUTRAL] Well, we don't determine patient responsibility, um, but the remaining balance that would be up to the provider to determine next steps.
[CUSTOMER][NEUTRAL] No, we don't determine patient responsibility, um, but the remaining balance that would be able to the provider to determine.
[CUSTOMER][POSITIVE] OK, got it, thank you.
[CUSTOMER][POSITIVE] All right in this, uh, and I thank you for the information for helping me out. That will be all for now. And may I have a car reference number, please?
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] but you can use my name is [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] Well, thank you very much for calling APLA and I hope you have a great day.
[CUSTOMER][POSITIVE] Well thank you very much for calling APLA. I hope you have a great day. Thank you, you have a good one bye bye.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] OK bye.