AccountId: 011433970860
ContactId: a4b65847-6210-48c3-bd6a-c2e740585d9e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 309850 ms
Total Talk Time (AGENT): 110119 ms
Total Talk Time (CUSTOMER): 117957 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/14/a4b65847-6210-48c3-bd6a-c2e740585d9e_20250314T18:22_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from provider's office to check on claims.
[AGENT][POSITIVE] I'd be happy to assist with claims today if I can get a good call back number for you.
[CUSTOMER][NEUTRAL] Yeah, sure. It is [PII] and it's a direct line.
[AGENT][NEUTRAL] And what is the patient's name? um, his policy number?
[CUSTOMER][NEUTRAL] Uh, the policy number is 01940423.
[AGENT][NEUTRAL] Patient's name and date of birth.
[CUSTOMER][NEUTRAL] Uh, the first name is uh [PII], and the last name is uh [PII], and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that information. Please be advised the verification of coverage is not a guarantee of payment. I do show the policy is currently active. Wait now, is this for?
[AGENT][NEUTRAL] Inpatient or outpatient?
[CUSTOMER][NEUTRAL] It is for outpatient?
[AGENT][NEUTRAL] OK, effective date is [PII].
[AGENT][NEUTRAL] And I do show for outpatient.
[AGENT][NEUTRAL] The percurrence is $250.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What is the date of service?
[CUSTOMER][NEUTRAL] Uh, you said like the
[CUSTOMER][NEUTRAL] Uh, yeah. It is for [PII].
[AGENT][NEUTRAL] And your tax ID.
[CUSTOMER][NEUTRAL] Yes, sir. Just a moment.
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] OK, I'm showing the claim was denied because the maximum benefit had already been paid out.
[CUSTOMER][NEUTRAL] Uh, uh, can you please help me like, uh, which of the, uh, uh, so that CPT was, uh, denied as maximum. Please may I know like uh how many visits are, uh, allowed for that number for that particular CPT?
[AGENT][NEGATIVE] It was denied because their outpatient benefit for that occurrence had maxed out we had already paid it out to another provider. There was no more benefits left for that occurrence.
[CUSTOMER][NEUTRAL] Uh, OK. May I know when was the last, uh, it was exhaustion on?
[AGENT][NEUTRAL] Um, and a claim that we processed on [PII].
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Uh, uh, if I, if it is, it was exhaustion on, uh, [PII], may I know like it was billed on [PII], right? So was there any claim from yours, uh, from any other provider with the same date of service for that CPT?
[AGENT][NEUTRAL] That was a we received we received your claim [PII] regardless of what the data service was you didn't file the claim until we didn't get it until [PII] we received a claim from another provider on [PII], so we processed first in first out.
[AGENT][NEUTRAL] So the benefits were already maxed when we got your claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So, uh, may I know like how many benefits that did that uh member had before?
[AGENT][NEUTRAL] It's $250 per occurrence. $250 per occurrence.
[CUSTOMER][NEUTRAL] For that particular activity?
[CUSTOMER][NEUTRAL] 200.
[AGENT][NEUTRAL] And that was paid to another provider on [PII].
[CUSTOMER][NEUTRAL] But I got that.
[CUSTOMER][POSITIVE] OK. Thank you so much for that information. And just as an additional information, can I have the uh billing address, please?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that's in [PII]?
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Coma, and can you please help me with the [PII] family filing.
[AGENT][NEUTRAL] It's 60 days from the date of denial.
[CUSTOMER][NEUTRAL] OK. And uh for this, uh, can you please help me with the date and the process it?
[AGENT][NEGATIVE] We received the claim on [PII], claim denied on [PII].
[CUSTOMER][POSITIVE] [PII]. OK, thank you so much for that information. And yeah, that's the only claim I'm having right now. Thank you so much. Can I have your girlfriend's number, please?
[AGENT][NEUTRAL] Reference is just my name [PII] last initial [PII], and the date and time of the call. Was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No, that's the only claim I was having. Thank you so much for that. Have a happy weekend. Bye-bye.
[AGENT][POSITIVE] Thank you for calling APL have a good day.