AccountId: 011433970860
ContactId: 999d5fe3-2522-4157-97de-62c9989acf4e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 430630 ms
Total Talk Time (AGENT): 151737 ms
Total Talk Time (CUSTOMER): 252145 ms
Interruptions: 21
Overall Sentiment: AGENT=1.8, CUSTOMER=2.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/06/999d5fe3-2522-4157-97de-62c9989acf4e_20250106T16:14_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling ATL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hey, there. It's uh [PII] on this side. I was wondering if you can help me out with the claims, please.
[AGENT][NEUTRAL] Yeah, I can help you out with the claim today and what do you mind, [PII] if I get a good call back number?
[CUSTOMER][NEUTRAL] Yeah, definitely. [PII].
[AGENT][POSITIVE] Perfect. And what is the policy number we're looking at, [PII]?
[CUSTOMER][NEUTRAL] Uh, policy number.
[CUSTOMER][NEUTRAL] That'll be 244-857-2.
[AGENT][NEUTRAL] 244-857-2, did I hear that correct?
[CUSTOMER][NEUTRAL] 244-857-2 did I hear that correct? Yep.
[CUSTOMER][NEUTRAL] I think.
[AGENT][NEUTRAL] And your patient's first and last name and date of birth, please?
[CUSTOMER][NEUTRAL] Is your first and last name and date of birth please? It's uh [PII]. Date of birth [PII].
[CUSTOMER][NEUTRAL] Alright
[AGENT][POSITIVE] Perfect, thank you so much. And what is the date of service for the claim you want to look at?
[CUSTOMER][NEUTRAL] Perfect thank you so much and what is the data service for the plan you want to look at? [PII].
[AGENT][NEUTRAL] And the bill amount please?
[CUSTOMER][NEUTRAL] And $2800.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] On
[CUSTOMER][NEUTRAL] You said $2300. Uh, 28 $100 2828. OK, I'm so sorry, give me one second. I think I find the same.
[AGENT][NEUTRAL] You said $2300?
[AGENT][NEUTRAL] 28. OK. I'm so sorry. Give me one second. I think I found the claim then.
[CUSTOMER][NEUTRAL] Oh, OK, there you go.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] And what is the name of the facility on file for the claim?
[CUSTOMER][NEUTRAL] And what is the name of the facility on file for the claim? Uh, North Shore Hematology oncology Associates.
[AGENT][NEUTRAL] OK, sorry, it was not that one I pulled up. Give me one second though. I have a couple others I can check.
[CUSTOMER][NEUTRAL] I think that
[AGENT][POSITIVE] OK, I see it right here. Thank you so much for your patience and.
[CUSTOMER][POSITIVE] OK, I see it right here. Thank you so much for your patience and.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Alright, I see that we received your claim on [PII].
[CUSTOMER][NEUTRAL] Alright, I see that we received your claim on [PII].
[AGENT][NEUTRAL] We processed the claim on [PII].
[CUSTOMER][NEUTRAL] We processed the payment on [PII].
[AGENT][NEUTRAL] I do have your claim number listed as 3521973.
[CUSTOMER][NEUTRAL] I do have your claim number listed as 3521973.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] I show that that claim was denied. I have the remark codes read.
[CUSTOMER][NEUTRAL] I show that that claim was denied. I have the remarks close read.
[AGENT][NEUTRAL] Um, benefits payable under the certificate are limited to those outlined in the schedule of benefits. This is not a covered loss under the plan. Therefore, no amount payable for this expense.
[CUSTOMER][NEUTRAL] Um, benefits payable under the certificate are limited to those outlined in the schedule of benefits. This is not a covered loss under the plan. Therefore, no amount payable for this expense.
[AGENT][NEUTRAL] And it says that for all of the codes.
[CUSTOMER][NEUTRAL] And it does that for all of the show. OK, so basically the whole claim is not cover under the patient's plan?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Correct. OK. Uh, may I know the, may I please know the patient's plan name by any chance?
[AGENT][POSITIVE] Oh, yes, absolutely, and hang on one second.
[CUSTOMER][POSITIVE] Oh yes, absolutely and turn on one.
[CUSTOMER][NEUTRAL] No
[AGENT][NEUTRAL] I'm so sorry. I actually had a different claim number typed in and I actually have a different claim denial reason.
[CUSTOMER][NEUTRAL] I'm so sorry. I actually had a different claim number typed in and I actually have a different claim denial reason. Yeah, sure, go ahead. What's the denial reason? the the claim number I pulled up the wrong one. Yeah, sure. Yeah sure.
[AGENT][NEUTRAL] And can I give you the claim, the claim number? I pulled up the wrong one entirely, so I have a different claim number for you too.
[AGENT][NEUTRAL] It is 353-373.
[CUSTOMER][NEUTRAL] It is 353-373. OK.
[CUSTOMER][NEUTRAL] And then it is just the one and it says the maximum for outpatient office visits due to sickness and has been. OK. I is it possible to get the explanation of benefits faxed to us?
[AGENT][NEUTRAL] And then it is just the one to denial reason and it says the calendar year maximum for outpatient office visits due to sickness and or accident have been met for this calendar year.
[AGENT][POSITIVE] Yes, I can absolutely do that. Give me one second to get that EOB pulled up for you.
[CUSTOMER][POSITIVE] Yes, I can absolutely do that. Give me one second to get that EOV pulled up for you. Yeah, sure.
[CUSTOMER][NEUTRAL] I think
[CUSTOMER][NEUTRAL] company.
[CUSTOMER][NEUTRAL] uh.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] All righty. And do you want that made attention to yourself, [PII]?
[CUSTOMER][POSITIVE] Alrighty and you want that to yourself? Yes, please, that would be great.
[AGENT][POSITIVE] Wonderful. And what's that fax number?
[CUSTOMER][POSITIVE] Wonderful. And you have fax number? The fax number will be [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] [PII]. Yeah that's correct.
[AGENT][POSITIVE] Perfect and
[CUSTOMER][POSITIVE] Perfect and I am getting send on that fax for you now. You should get it within the next.
[AGENT][POSITIVE] I am hitting send on that fax for you now. You should get it within the next 5 to 15 minutes.
[CUSTOMER][POSITIVE] 5 to 15 minutes. OK. Great. Perfect. Thank you so much. Um, um, and may I please have the call reference number by any chance?
[AGENT][POSITIVE] Yes, my pleasure.
[AGENT][NEUTRAL] You betcha. It's my name, [PII], first initial last name, [PII], and today's date.
[CUSTOMER][POSITIVE] You bet. It's my name, [PII] First and last name, [PII] today's date. OK, perfect. I thank you so much. I hope you have a wonderful rest of your day.
[AGENT][POSITIVE] Good, you too. Thank you so much, [PII]. You take care.
[CUSTOMER][POSITIVE] You too thank you so much [PII]. Yeah, bye bye.
[AGENT][NEUTRAL] Bye bye.