AccountId: 011433970860
ContactId: 9f4824fc-b905-42d0-958f-d5ecb7121e71
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 688320 ms
Total Talk Time (AGENT): 259478 ms
Total Talk Time (CUSTOMER): 163124 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/14/9f4824fc-b905-42d0-958f-d5ecb7121e71_20250214T19:33_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from the provider office to check the claim status.
[AGENT][POSITIVE] OK, and I'll be more than happy to assist you with the claim status, [PII]. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] It's 3
[AGENT][NEUTRAL] And may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah. Patient name, [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] And the policy number?
[CUSTOMER][NEUTRAL] Policy number? Uh
[CUSTOMER][NEUTRAL] 02466349
[AGENT][POSITIVE] Thank you. Hold on one moment.
[AGENT][NEUTRAL] And may I have the date of service for the claim you like me to check on?
[CUSTOMER][NEUTRAL] Yeah, the date of services, sir.
[CUSTOMER][NEUTRAL] [PII], bill on $45 even.
[AGENT][NEUTRAL] And this is for [PII], correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. Are the other claims for him as well, or?
[AGENT][NEUTRAL] These are the other two are different members.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Uh, for the next store it's for same member.
[AGENT][NEUTRAL] OK, what are the other dates of service and total bill?
[CUSTOMER][NEUTRAL] [PII] $45 even.
[AGENT][NEUTRAL] OK, and the last claim?
[CUSTOMER][NEUTRAL] It's for different members.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Clinical radiologist.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, so the [PII] claim was received on [PII]?
[AGENT][NEUTRAL] The claim number is 3469884.
[AGENT][NEUTRAL] And all the information provided is a verification of benefits, not a guarantee of payment.
[CUSTOMER][NEUTRAL] Can you tell me the claim number?
[AGENT][NEUTRAL] Also on June
[AGENT][NEUTRAL] 346.
[AGENT][NEUTRAL] 9884.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the status of this claim?
[AGENT][NEUTRAL] And also on
[AGENT][NEGATIVE] Also on [PII], the claim was denied. Well, it's actually on hold. Um, our records indicate that premium for this data service was not received. Therefore, benefits are not payable, um, so this one was in fact denied. It wasn't waiting for eligibility.
[CUSTOMER][NEUTRAL] OK. May I know the patient there?
[AGENT][NEUTRAL] You said the patient eligibility?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] So the policy is still active, I'm sorry, the policy was effective from [PII].
[CUSTOMER][POSITIVE] OK. Thank you so much. Is it for this data service patient is term, right, OK.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then for the
[CUSTOMER][POSITIVE] Thank you so much. Mm.
[AGENT][NEUTRAL] Did you need the [PII] claim?
[CUSTOMER][NEUTRAL] Continue.
[CUSTOMER][NEUTRAL] I said [PII], it's [PII], sorry.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] So the um second one is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so it was denied for the same reason, but let me give you the um received process date and the claim number.
[AGENT][NEUTRAL] So it was received on [PII]?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that's claim number 3,471,150?
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] And on [PII]?
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Mm, OK, OK. May I move on to the next one.
[AGENT][NEUTRAL] Sure. Did you need the date that the claim was processed?
[CUSTOMER][NEUTRAL] Yeah, it's, you said [PII], right?
[AGENT][NEUTRAL] Right, [PII] it was processed as well. OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] Uh, can you, uh, for the previous claim, can you provide me the, is denied or it's still, uh, pending for the eligibility detail? Is it denied, right?
[AGENT][NEGATIVE] They're both denied because premium was not received for that data service.
[CUSTOMER][NEUTRAL] OK. OK. For the next one, the member ID is
[AGENT][NEUTRAL] Hold on one moment, let me note this policy.
[AGENT][NEUTRAL] OK. And the next member's policy number?
[CUSTOMER][NEUTRAL] 01902342
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] There is will be date of birth, [PII].
[AGENT][NEUTRAL] Thank you for that. And again, all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you like me to check on?
[CUSTOMER][NEUTRAL] Yeah, it's uh [PII]. total bill amount, $280 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And that was [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] 3
[AGENT][NEUTRAL] 786 hold on one moment the um.
[CUSTOMER][NEUTRAL] Wait
[AGENT][NEUTRAL] Alright, so I'm showing the claim was received on [PII].
[AGENT][NEUTRAL] The claim number is 3444786.
[CUSTOMER][NEUTRAL] You said that uh start with the 3, right? Claim number?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yes, 344.
[CUSTOMER][NEUTRAL] OK, receive it?
[CUSTOMER][NEUTRAL] 786. OK. May I know the received date? I'm not noted that.
[AGENT][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] It was received on [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it processed on [PII]?
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEGATIVE] And it was denied because the outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] The outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] OK. One second.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes, I'm here.
[CUSTOMER][NEUTRAL] Uh, can you tell me that, uh, again? Outpatient means, uh, can you elaborate this?
[AGENT][NEUTRAL] So, the patient has up to $1000 per calendar year that they can use for outpatient expenses. This denial reason is saying by the time your claim was received, the $1000 for outpatient benefits have been used, so we cannot pay out on your claim because they've already used all their benefits for the year.
[CUSTOMER][NEUTRAL] OK. For the annual deductible amount is 2000, right, for this patient?
[AGENT][NEUTRAL] This policy does not have a deductible for their secondary policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So for this claim, we have to bill the patient, right? Remaining balance?
[AGENT][NEUTRAL] So it
[AGENT][NEUTRAL] We don't determine patient responsibility because we're not a major medical insurance company.
[CUSTOMER][NEUTRAL] OK. Do you want primary UB to process this claim?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Do you want actually this claim is primary process and paid this claim?
[CUSTOMER][NEUTRAL] Do you want primary EOB?
[AGENT][NEUTRAL] Um, the primary explanation of benefits is not needed. So primary has their own benefits and secondary has their benefits. So the it could have been paid out, but they've used their max by the time your claim was received, so there's nothing left to pay with. They've used all their benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The max was $1000. I'm sorry?
[CUSTOMER][NEUTRAL] OK. Can you provide me your account?
[CUSTOMER][NEUTRAL] Mm, yes. Continue.
[AGENT][NEUTRAL] I was just saying the max is $1000 and they used the full $1000 by the time your claim came in.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, can you provide me a call reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name and today's date. Again, my name is [PII] The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, [PII]