AccountId: 011433970860
ContactId: ab43c952-76e0-4f4f-b110-10a9a9bd2f5e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 523679 ms
Total Talk Time (AGENT): 118657 ms
Total Talk Time (CUSTOMER): 110001 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/13/ab43c952-76e0-4f4f-b110-10a9a9bd2f5e_20250313T14:55_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling AP. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm here to check on our claim status today. Could you please provide me your name again?
[AGENT][NEUTRAL] Yes, my name is [PII] and you said your name was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you, um, I can help you with the claim status, sir. Can I please get the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Yes. First, the policy ID number is 02512377 and the member's name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK. Let me pull up that policy real quick.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and then what is the date of service of the claim?
[CUSTOMER][NEUTRAL] Data service is [PII] for the total charges of $1,057 even.
[AGENT][NEUTRAL] OK and then can you please give me the name of the facility you're calling for?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] The facility name is not on Community Medical Associates.
[AGENT][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] I'm going to put you on a brief hold while I this screen for us, [PII], and I'll be right back.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thanks
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding for CJ so looking on data service of [PII].
[AGENT][NEUTRAL] Of [PII] in the amount of $1,057 I do not find a claim on file.
[CUSTOMER][NEUTRAL] Um, let me provide you the claim number.
[AGENT][POSITIVE] Yes, that would be helpful. What is that, please?
[CUSTOMER][NEUTRAL] 355-0066
[AGENT][NEUTRAL] That's 3550.
[AGENT][NEUTRAL] 066.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Let's see if I can find that.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, I'm gonna put you on a brief hold while I pull this claim in.
[AGENT][NEUTRAL] No, I'll be right back, sir.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, TJ, looking at claim number 355006, the claim was for two reasons. One is the benefit maximum calendar year had been met, and the other was vaccines are not covered under the patient's policy.
[CUSTOMER][NEUTRAL] Um, one moment. Your voice is just cutting in and out. Could you please, uh,
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] Could you hear me now?
[AGENT][NEGATIVE] OK, so the, the, yes I can hear you. I was denied because the benefit.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Has been maxed out for the calendar year and because vaccines are not covered under the patient's policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Vaccines are not covered under the member's policy, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. Upon checking, the CBT 99214 has been delayed for maximum benefit has been met, right? And you're only allowed for uh
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] 4 times per year, right? But uh upon checking here, we didn't build the CPT for 4 times in a year.
[CUSTOMER][NEUTRAL] So could you please take the claim back for a review or reprocess for a review.
[AGENT][NEUTRAL] No, um, just because it wasn't.
[AGENT][NEGATIVE] Used 4 times from your company doesn't mean that it wasn't used from another company.
[CUSTOMER][NEUTRAL] OK. So, may I know
[CUSTOMER][NEUTRAL] On which day the last maximum benefit was met?
[AGENT][NEUTRAL] I can't give that information because you're not the provider that use.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And for the CPT 90739 and the CPT 90741, that the vaccines are not covered under the member's policy, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK. So could you please provide me the call reference number?
[AGENT][NEUTRAL] Yes sir, you can use my name [PII] and today's date.
[CUSTOMER][POSITIVE] OK. Thank you for assisting me today. Have a nice day.