AccountId: 011433970860
ContactId: a3d35dd2-3489-4798-a315-a005c47907ad
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 972960 ms
Total Talk Time (AGENT): 376041 ms
Total Talk Time (CUSTOMER): 359199 ms
Interruptions: 4
Overall Sentiment: AGENT=0.9, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/a3d35dd2-3489-4798-a315-a005c47907ad_20250219T18:56_UTC.wav
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[AGENT][NEUTRAL] Good afternoon thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, I'm [PII] calling from provider's office, verify claim status.
[AGENT][NEUTRAL] OK, [PII], you're needing claim status, is that correct?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Yeah, that's correct.
[AGENT][POSITIVE] Yes, I can help you with that and [PII], what is your callback number?
[CUSTOMER][NEUTRAL] Yeah, this one is [PII] the [PII] [PII].
[AGENT][NEUTRAL] Thank you. And how many clients, [PII], do you have to check status on?
[CUSTOMER][POSITIVE] Yeah, that's correct.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes sir, how many claims do you have to check status on today?
[CUSTOMER][NEUTRAL] I only one claim, ma'am.
[AGENT][NEUTRAL] OK, and what is that member's policy number?
[CUSTOMER][NEUTRAL] Yeah, that one is 025361.
[CUSTOMER][NEUTRAL] 97
[AGENT][POSITIVE] Thank you, one moment please.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Any any information that I do provide for you today, [PII] will be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] The patient's name is, as per the patient's first name is [PII], and last but the last name also is [PII] Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] And what is the date of service and total bill amount please [PII]?
[CUSTOMER][NEUTRAL] Yeah, yeah, sure. Your date of service is [PII]. Climb bill amount is $159.
[AGENT][POSITIVE] Thank you, one moment.
[AGENT][NEUTRAL] OK, so there is no claim on file for him for that data service and total bill amount.
[CUSTOMER][NEUTRAL] Is [PII], there is no claim on file?
[AGENT][POSITIVE] Correct. That is correct. This is for dental.
[CUSTOMER][NEUTRAL] Uh, then I will, uh, no, ma'am. It's a medical claim.
[AGENT][NEUTRAL] OK, you gave me a dental policy number.
[CUSTOMER][NEUTRAL] This is a dental policy number?
[AGENT][NEUTRAL] Yes, 3 is.
[CUSTOMER][NEUTRAL] This policy number is uh dental, right? It's 025361. OK. This is a dental policy number. So, please verify with the patient's name and date of birth?
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] Yes, so we already did that. Mhm.
[CUSTOMER][NEUTRAL] Is unable to find the patient information, right?
[AGENT][NEUTRAL] Just one moment, what claim number did you file the claim under?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] What policy number rather did you file the claim under?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, the policy number is I already told you, ma'am, is the policy number is 02.
[AGENT][NEUTRAL] Yes, sir.
[AGENT][NEUTRAL] Uh, and I'm telling you that that is an incorrect policy number. If this is for a medical claim, that is an incorrect policy number you gave me a dental policy number, not a medical policy number.
[CUSTOMER][NEUTRAL] In Kaur.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] So, that one is the dental policy number, please wait, uh, I have the.
[AGENT][NEUTRAL] So just one moment
[CUSTOMER][NEUTRAL] It's OK, you find it just a minute, just a minute, you find the patient information, right?
[AGENT][NEUTRAL] If it is a medical claim, I will need to give you the correct policy number that you will need to update in your system.
[AGENT][NEGATIVE] Because that number that you gave to me is not correct.
[CUSTOMER][NEUTRAL] I think it was
[CUSTOMER][NEUTRAL] OK, what's the uh medical policy number?
[AGENT][NEUTRAL] The correct number is 025362677 with an effective date of [PII].
[CUSTOMER][NEUTRAL] Please
[CUSTOMER][NEUTRAL] Uh, please confirm is 0253.
[CUSTOMER][NEUTRAL] 626-7, that's the medical policy number, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Yes, OK, please provide your name.
[AGENT][NEUTRAL] [PII] and give me a moment so that I can check to see if we.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh [PII]
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] [PII], right.
[AGENT][NEUTRAL] I, [PII].
[CUSTOMER][NEUTRAL] [PII], I got it. So, I need a claim status, [PII].
[AGENT][NEUTRAL] Let me see if we received the claim and processed it under the correct number, [PII], one moment please.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] And again you said data services [PII], is that correct?
[CUSTOMER][POSITIVE] Yeah, that's correct.
[AGENT][NEUTRAL] For $159 is that also correct?
[CUSTOMER][POSITIVE] Yeah, that's correct.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] OK, so this claim was received, the receipt and we processed it under the correct policy number.
[CUSTOMER][NEUTRAL] If you
[AGENT][NEUTRAL] The receipt date was [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] It was processed and denied on [PII].
[AGENT][NEUTRAL] The claim number is 3523356.
[CUSTOMER][NEUTRAL] The reason?
[AGENT][NEUTRAL] The states calendar year maximum on diagnostic services has been met.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] People
[CUSTOMER][NEUTRAL] Uh, if you don't mind, just a second, uh.
[CUSTOMER][NEUTRAL] May I know the claim denied date one more time?
[AGENT][NEUTRAL] It was denied on [PII].
[CUSTOMER][NEUTRAL] [PII] or [PII].
[CUSTOMER][NEUTRAL] [PII] denied reason is now maximum diagnosis, the diagnosis code was invalid, right?
[AGENT][NEUTRAL] No, so that's not what I said. What I said was calendar year maximum.
[CUSTOMER][NEUTRAL] 10
[AGENT][NEUTRAL] On diagnostic services has been met.
[CUSTOMER][NEUTRAL] That means what you say the maximum benefit was exceeded, right?
[AGENT][NEUTRAL] Calendar your maximum on diagnostic services has been met.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Please repeat one more time, uh, then I'll if you don't mind.
[AGENT][NEUTRAL] Calendar year maximum on diagnostic services has been met.
[CUSTOMER][NEUTRAL] Calendar diagnosis.
[AGENT][NEUTRAL] No, sir.
[CUSTOMER][NEUTRAL] Then
[CUSTOMER][NEUTRAL] Calendar maximum.
[CUSTOMER][NEUTRAL] Diagnosis.
[AGENT][NEUTRAL] Um, no, not diagnosis, diagnostic.
[CUSTOMER][NEUTRAL] Then
[CUSTOMER][NEUTRAL] Diagnostics then?
[AGENT][NEUTRAL] Services
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Has been met.
[CUSTOMER][NEUTRAL] Post and meth, right?
[AGENT][NEUTRAL] Has been met.
[CUSTOMER][NEUTRAL] Past P A S T, right?
[AGENT][NEUTRAL] No, no, no, no. HAS has been met.
[CUSTOMER][NEUTRAL] As then H A S S, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] As then
[AGENT][NEUTRAL] Math.
[CUSTOMER][NEUTRAL] T H E and then.
[CUSTOMER][NEUTRAL] the net.
[AGENT][NEGATIVE] Oh God, no, no, no. OK. HAS.
[CUSTOMER][NEUTRAL] In the
[AGENT][NEUTRAL] The next word is B E E N.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The next word MET.
[CUSTOMER][NEUTRAL] It has been met, right? Has been met.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yeah, the maximum diagnostics service has been met, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, what can I do for this client?
[AGENT][NEUTRAL] If you disagree with the decision, you have 180 days to file an appeal.
[CUSTOMER][NEUTRAL] 390
[CUSTOMER][NEUTRAL] Uh, but the initially claimed as a maximum benefit, but you see is a different one. It's a maximum benefit, right? That's OK. I need a little more question.
[AGENT][NEUTRAL] Um,
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] Uh, I
[CUSTOMER][POSITIVE] Yeah, great.
[AGENT][NEUTRAL] I have read you the denial remarks several times on this particular claim in this data service calendar year maximum on diagnostic services has been met. If you disagree with that, then you would need, you have 180 days from the date that the claim was processed to file an appeal.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um, ma'am.
[CUSTOMER][NEUTRAL] Please wait. First of all, please understand my question. Oh, you initially claimed it as the maximum benefit, but you say a different. This one is valid denial, but you need your medical records. Please wait for one moment.
[AGENT][POSITIVE] Yes, I will.
[AGENT][NEUTRAL] No, sir. I didn't say medical records.
[AGENT][NEUTRAL] I never said anything about medical records.
[CUSTOMER][NEUTRAL] It's OK. Thank you for being on hold. I appreciate your patience awaiting my call. It's OK, ma'am. Please confirm, you said the diagnosis code was invalid, right? It's all as Romeo number 42.
[AGENT][NEUTRAL] No, so that's not what I said.
[AGENT][NEUTRAL] That's not what I said.
[CUSTOMER][NEUTRAL] It's OK. You, so you provide only a calendar maximum diagnosis service.
[CUSTOMER][NEUTRAL] has been met means what? I cannot clearly understand, ma'am. I need a property and reason.
[AGENT][NEUTRAL] That is the denial reason. This is not a major medical insurance plan. This is a limited benefit plan.
[CUSTOMER][NEUTRAL] This is not a major medical plan, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Well.
[CUSTOMER][NEUTRAL] This is not a major medical plan. This is a dental plan, right?
[AGENT][NEUTRAL] No, sir, it is not. It's a limited benefit plan. Hospital indemnity limited benefit plan.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, what can I do for this, ma'am? You need your medical records, right?
[AGENT][NEUTRAL] I, no, sir, I just never said anything about medical records.
[CUSTOMER][NEUTRAL] Then, what can I do?
[AGENT][NEUTRAL] I explained that if you disagree with the decision, you have 180 days from the date of the denial that an appeal may be filed.
[CUSTOMER][NEUTRAL] You say that disagree for this denial, you was trying to say submit the appeal, right?
[AGENT][NEUTRAL] If that is what you want to do, if you disagree with the decision.
[CUSTOMER][NEGATIVE] I cannot accept this one. Please send back for reprocess. I cannot accept this deny. Please send back.
[AGENT][NEUTRAL] Uh, no, sir, I can't, you can request an appeal if you disagree with the decision, but I cannot send for reprocessing.
[CUSTOMER][NEUTRAL] OK can you try to submit the appeal with the medical records, right, for decision.
[AGENT][NEUTRAL] If you disagree with the decision and you would like to file an appeal, you may have 180 days from the date of the denial that I gave you.
[CUSTOMER][NEUTRAL] Please wait.
[CUSTOMER][POSITIVE] OK. Thank you for being on hold. I appreciate your patience awaiting my call. Uh, diagnostics, uh, the diagnostic service, how many units allowed per year.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] On this policy for this limited benefit plan, it is one test per calendar year.
[CUSTOMER][NEUTRAL] One
[AGENT][NEUTRAL] 1
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Allowed only one, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] But it is billed only once, ma'am. But you say that this is a different uh.
[AGENT][NEUTRAL] Sir, he had, there was a prior claim processed before this claim was received that exhausted his benefits, and I cannot provide you information on another provider's claim.
[CUSTOMER][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] Yes, it is already a paid to a different provider, right?
[CUSTOMER][NEUTRAL] That's OK. You cannot provide a different, yeah, that's OK. Another claim, you cannot provide uh provide the information. I need a little more question. A payment may be included with the facilities claim.
[AGENT][POSITIVE] On another claim, yes sir, that is correct.
[CUSTOMER][NEUTRAL] With build on other data service.
[AGENT][NEUTRAL] Uh, I'm sorry, what was your question again? [PII]? You're
[CUSTOMER][NEUTRAL] Um, my question is, uh, yeah, yep, yeah, yeah, I still miss a payment maybe.
[AGENT][NEUTRAL] Oh, we only have one claim, yes, so we only have one claim on file for that bill amount and that data service.
[CUSTOMER][NEUTRAL] No, ma'am, my question is, just a minute.
[CUSTOMER][NEUTRAL] A payment may be
[CUSTOMER][NEUTRAL] Mhm. My question, this one is uh a payment may be included with the facilities claim for with other build on the date of service.
[AGENT][NEUTRAL] What is the total bill amount on the claim you're asking about?
[CUSTOMER][NEGATIVE] No, no, no, no, no.
[AGENT][NEUTRAL] Yes sir, I can't provide you, yes sir, I cannot provide you information on any other claim other than the one you're calling about.
[CUSTOMER][NEUTRAL] Payment
[CUSTOMER][NEUTRAL] OK. It's OK, it's OK. You cannot.
[CUSTOMER][NEUTRAL] It's OK, you cannot have that information. It's OK.
[CUSTOMER][POSITIVE] It's OK. Thank you. It's OK. Thank you for the information, ma'am.
[AGENT][NEUTRAL] OK, you're very welcome and if you need a copy of that explanation of benefits, you may print that, [PII] by going to our portal which is located at secured.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] [PII] and print that if you need a copy of it.
[CUSTOMER][NEUTRAL] It's OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It's OK, provide the call reference number. Your claim number is 2523.
[CUSTOMER][NEUTRAL] 356 that's a claim number, right? Call reference number please.
[AGENT][NEUTRAL] 3, the claim number is 352-3356, is that what you have?
[CUSTOMER][NEUTRAL] Yeah, 352-335-6 call reference number please.
[AGENT][NEUTRAL] That is correct, my name in today's date.
[CUSTOMER][POSITIVE] The names and today's dates. OK. Thank you, [PII]. Have a wonderful day. Bye-bye.
[AGENT][POSITIVE] That is correct. You're welcome and you too, [PII]. Thank you again for calling APL. I hope you have a nice evening.
[CUSTOMER][NEUTRAL] Bye.