AccountId: 011433970860
ContactId: a1240529-737a-4563-b27c-06e923f6b606
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 405899 ms
Total Talk Time (AGENT): 144558 ms
Total Talk Time (CUSTOMER): 169460 ms
Interruptions: 0
Overall Sentiment: AGENT=1.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/26/a1240529-737a-4563-b27c-06e923f6b606_20250326T16:31_UTC.wav
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[AGENT][POSITIVE] Morning, thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Good morning, [PII]. We shall decide from provider's office.
[AGENT][NEUTRAL] And I'm sorry, can you spell your name for documentation?
[CUSTOMER][NEUTRAL] Sure, [PII]. It's [PII], if I'm getting right, your name is spelled like [PII], right?
[AGENT][NEUTRAL] Well, it's actually [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] May I know the initial to last name [PII]?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Perfect.
[AGENT][POSITIVE] And it would be my pleasure to assist you. What is a good callback number, [PII]?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And [PII], what is the policy number for the patient, please?
[CUSTOMER][NEUTRAL] 01635430. M as in Mike, L as in Lima, number 8.
[AGENT][NEUTRAL] Thank you. And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] That's [PII].
[AGENT][NEUTRAL] And date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] And [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, actually, this claim was denied for max benefit reach.
[AGENT][NEUTRAL] All right. And do you have that claim number?
[CUSTOMER][NEUTRAL] Yes, I do have a claim number. Just give me one minute for that.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So the claim number is 3546834.
[AGENT][NEUTRAL] And the facility name, please?
[CUSTOMER][NEUTRAL] Facility name is West Boca Medical Center.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] All right, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yes, sir. I'm showing with the payment of that claim, the maximum benefit has been met.
[CUSTOMER][NEUTRAL] OK. However, we have called earlier and what
[CUSTOMER][NEUTRAL] We got to know that 64, just give me one minute.
[CUSTOMER][NEGATIVE] That the procedures which was denied for max benefit reach.
[CUSTOMER][NEUTRAL] Uh, just give me one minute. The procedure which was denied for max benefit reach.
[CUSTOMER][NEUTRAL] Has 20.
[CUSTOMER][NEUTRAL] Just give me one minute. I'm finding my previous notes.
[AGENT][POSITIVE] That's fine. Take your time.
[CUSTOMER][NEUTRAL] Maybe
[CUSTOMER][NEUTRAL] I mean.
[CUSTOMER][NEUTRAL] I'm gonna be.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK. So the procedure is allowed 20 visitors visits in 12 months, right? And we have only billed one visit for each procedures.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Procedure 24147.
[AGENT][NEUTRAL] No, sir.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now is this for a facility clean?
[CUSTOMER][NEUTRAL] Yeah, it's for a hospital outpatient.
[AGENT][NEUTRAL] Right, so we, we pay for the facility charges.
[AGENT][NEUTRAL] Now this policy max for outpatient facility, they do have a calendar year max benefit of $2000. It's not limited by visits, it's limited by dollar amount.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that is a verification of coverage and not a guarantee of payment.
[CUSTOMER][NEUTRAL] Per year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So for hospital charges, it has a maximum of $2000 right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] For hospital charges.
[CUSTOMER][NEUTRAL] OK. May I know about the appeal procedure?
[AGENT][NEUTRAL] Appeal procedure is a time frame is 180 days from the date of denial.
[CUSTOMER][NEUTRAL] One or 2 days. OK.
[AGENT][NEUTRAL] We
[AGENT][NEUTRAL] Mhm. And we will need a formal appeal letter stating the reason that you are deny are appealing the claim decision.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that can be faxed directly to our claims.
[CUSTOMER][NEUTRAL] And where we can spend.
[AGENT][NEUTRAL] You can fax it or mail it.
[CUSTOMER][NEUTRAL] Fax
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. May I know the fax number first?
[AGENT][NEUTRAL] Fax number to our claims department is 877.
[AGENT][NEUTRAL] 365.
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] 9423. And what is the mailing address?
[AGENT][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm. Zip code is [PII].
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][POSITIVE] That's right.
[CUSTOMER][NEUTRAL] And what is the state?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] So the city is [PII] and the state is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. City [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] [PII]. Great.
[AGENT][NEUTRAL] And you have the claim number.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] [PII], it was a pleasure to assist you with that claim information. Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] Just need the call reference number now.
[AGENT][NEUTRAL] It would be my name in today's date.
[CUSTOMER][POSITIVE] Your name and today's date? OK, perfect, [PII]. Thank you so much for your kind help.
[AGENT][NEUTRAL] Yes, sir.
[AGENT][POSITIVE] It's been my pleasure to assist you. Anything else I can help you with?
[CUSTOMER][POSITIVE] That's all for today. Thank you.
[AGENT][POSITIVE] [PII], thank you for calling APL and you have a wonderful day.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh, may I know the zip code once again? [PII], [PII].
[AGENT][NEUTRAL] That's right. And the zip code is [PII].
[CUSTOMER][POSITIVE] [PII]. Perfect. Thank you.
[AGENT][POSITIVE] Thank you. Have a great day, [PII].
[CUSTOMER][NEUTRAL] You too. Bye-bye, [PII].
[AGENT][NEUTRAL] Bye-bye.