AccountId: 011433970860
ContactId: 9c3bc687-5d8a-40d0-8b62-2ca6815e5883
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 598750 ms
Total Talk Time (AGENT): 216203 ms
Total Talk Time (CUSTOMER): 96076 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/05/9c3bc687-5d8a-40d0-8b62-2ca6815e5883_20250505T12:50_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, [PII]. Good morning. This is [PII] here calling from provider's office to check on a claim status.
[AGENT][NEUTRAL] OK, [PII], you have one claim to check status on, is that correct?
[CUSTOMER][NEUTRAL] One moment, I'm checking for that.
[CUSTOMER][NEUTRAL] Oh, it's not one, it's, uh, including this, it's 4.
[AGENT][NEUTRAL] OK, [PII], yes, I can help you with that. And what is your callback number, please?
[CUSTOMER][NEUTRAL] Uh, callback number is [PII]. It's a direct call, no extension.
[AGENT][NEUTRAL] OK, thank you. So first off, [PII], you will use my name and today's date as each reference number for each one.
[AGENT][NEUTRAL] Also, any information provided on any claim that I check will be a verification of benefits and not a guarantee of payment. And lastly, if we do have the claims on file and you need a copy of the explanation of benefits, once you have the claim number, you can print that yourself by going to our portal at [PII]. Again, my name is [PII]
[CUSTOMER][POSITIVE] Thank you for that.
[AGENT][NEUTRAL] And, and what is your first patient's policy number?
[CUSTOMER][NEUTRAL] Sure, the policy number is 025.
[CUSTOMER][NEUTRAL] 05608.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][POSITIVE] Sure. Take your time.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] So the patient's first name is?
[CUSTOMER][NEUTRAL] [PII] and the last name is [PII]. Date of birth uh [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the date of service and total bill amount please [PII].
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] D of services on [PII] with the bill amount of $4,389. 14 cents.
[AGENT][NEUTRAL] Alright, give me the bills out one more time, please.
[CUSTOMER][NEUTRAL] Sure. 4389.14.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] What is the name of the facility?
[CUSTOMER][NEUTRAL] Facility name is Medical City, Fort Worth.
[AGENT][NEUTRAL] OK, so we did not have a claim on file for her for this data of service and that total bill amount.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] I'm so sorry. Give me just a moment. Let me look at one other, one other thing. Hold on, I believe we do have it. Hold on just one sec. You said 4389.14 is the amount?
[AGENT][NEUTRAL] Is that correct?
[CUSTOMER][POSITIVE] Yes, that's right.
[AGENT][NEUTRAL] OK, so this claim was received on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Actually,
[AGENT][NEGATIVE] Actually, that is not correct. It was received on [PII].
[AGENT][NEUTRAL] Processed on [PII].
[AGENT][NEUTRAL] The claim number is 3554874.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And this claim was denied?
[AGENT][NEUTRAL] And the reason for the denial on the claim, [PII], one moment while that information is pulling up.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] State's maximum benefit.
[AGENT][POSITIVE] For this state of service has been met.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] [PII], are you still there?
[CUSTOMER][POSITIVE] Yes, I'm still with you.
[AGENT][NEUTRAL] OK. Again, maximum benefit for this state of service has been met.
[AGENT][NEUTRAL] And do you need any other information on this claim?
[CUSTOMER][NEUTRAL] So, may I know for the which procedure code?
[AGENT][NEUTRAL] This is not a major medical plan?
[AGENT][NEUTRAL] This is a hospital indemnity limited benefit plan.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the maximum benefit payable was $50.
[AGENT][NEUTRAL] And that was paid on another claim that was received prior to yours being received.
[CUSTOMER][NEUTRAL] May I know how much is the total, uh,
[AGENT][NEUTRAL] I just gave you the bill. I just gave you the maximum amount.
[CUSTOMER][NEUTRAL] Maximum 50 years, ma'am.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] May I know how much the patient has met?
[AGENT][NEUTRAL] I just explained that this was paid on another claim that was received prior to your claim being received.
[CUSTOMER][NEUTRAL] So it's inclusive?
[AGENT][NEUTRAL] This is not, this is not a major medical plan. It only pays certain amounts for certain services and the maximum benefit was already reached for this state of service prior to your claim being received.
[CUSTOMER][NEUTRAL] With another claim number?
[AGENT][NEUTRAL] For the same data service.
[CUSTOMER][POSITIVE] Got you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And any other information you need on this one before we move on?
[CUSTOMER][NEUTRAL] Can I get the mailing address, family and the payer ID to send the card to claim?
[AGENT][NEUTRAL] It is the same as what you sent to before.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][POSITIVE] Thank you for your patience.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] So, it's a [PII].
[CUSTOMER][NEUTRAL] OK. Uh [PII].
[AGENT][NEUTRAL] Now, for this member's policy, it is a completely a different address that it was sent to?
[CUSTOMER][NEUTRAL] No,
[AGENT][NEUTRAL] That would have been [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the familyile limit would be?
[AGENT][NEUTRAL] There's no timely filing and an appeal must be filed within 180 days from the date of the decision and mailed to the first address that you gave me.
[CUSTOMER][NEUTRAL] And the payer ID would be?
[AGENT][NEUTRAL] For the initial claim.
[AGENT][NEUTRAL] Can you please hold for me, [PII], while you're looking up all your information?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Sure, take your time.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.