AccountId: 011433970860
ContactId: b6bf1287-657a-437f-9f99-7e530894152b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 417420 ms
Total Talk Time (AGENT): 189127 ms
Total Talk Time (CUSTOMER): 68740 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/13/b6bf1287-657a-437f-9f99-7e530894152b_20250313T14:29_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. My name is [PII]. I'm calling from Retina Group of Florida, and I was calling to check the claim status for a member for two claims.
[AGENT][NEUTRAL] OK, you have one member that you're needing to check 2 claim statuses for, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Hm, yes, ma'am. I can help you with that. And I, could you please spell your name for me?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. And [PII], what is [PII], what is your callback number, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And [PII], what is the member's policy number?
[CUSTOMER][NEUTRAL] Um, I have 1200057.
[AGENT][NEUTRAL] Thank you one moment please while I get the member's information pulled up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And any information that I do provide for you today, [PII] would be a verification of benefits. It's not a guarantee of payment. What is your patient's name please and their date of birth?
[CUSTOMER][NEUTRAL] First name is [PII]. Last name is [PII] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. One moment.
[AGENT][NEUTRAL] And what is the first day of service and total bill amount for her, please?
[CUSTOMER][NEUTRAL] It is [PII].
[CUSTOMER][NEUTRAL] And the total bill amount is.
[CUSTOMER][NEUTRAL] $13,440.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so this claim was received on [PII].
[AGENT][NEUTRAL] And it was processed on [PII].
[AGENT][NEUTRAL] The claim number is going to be 3557505.
[AGENT][NEUTRAL] And this claim has been denied, [PII], and the reason for the denial is, give me just one moment.
[AGENT][NEUTRAL] that information pulled up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, it states on here calendar year policy maximum of 4 doctor's office visits per person has been met. There are no further benefits available for this calendar year for this individual.
[CUSTOMER][NEUTRAL] OK, for a calendar per year?
[AGENT][NEUTRAL] Yeah. Yes, ma'am.
[AGENT][NEUTRAL] And I'll go ahead and give you our website. I if you need a copy of this explanation of benefits, you can go to our portal to print that and our portal website is secured. [PII].
[CUSTOMER][NEUTRAL] OK, yeah, I tried, but it wouldn't.
[AGENT][NEUTRAL] Now that you have the claim number.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You, you should be able to access it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And if for any reason you can't, you know, you should call us.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said you had another data service for her also?
[CUSTOMER][NEUTRAL] Yes, it was um [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the bill amount on that.
[CUSTOMER][NEUTRAL] Um, that bill amount is.
[CUSTOMER][NEUTRAL] The $13,440.
[AGENT][NEUTRAL] 13,440. Is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Now we do not have a claim on file for her for that data service. This policy was not actually active for that data service. This policy termed 112025. Give me just a moment. She has another policy with a different number for that data service, so let me, give me just a moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the policy that is currently active for her.
[AGENT][NEUTRAL] Again, it has a different number and it's 02592475.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that policy again active effective date [PII]. Now there is no claim on file for her for that data service under this policy either.
[CUSTOMER][NEUTRAL] OK, you said it was active one.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So, [PII].
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now when the claim is submitted to APO remember to send the primary insurance explanation of benefits as well because we do have to have that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Was there anything else that I can help you with this morning?
[CUSTOMER][NEUTRAL] No, that was it.
[AGENT][POSITIVE] OK, well then thank you so much for calling APO and I hope you have a great day.
[CUSTOMER][NEUTRAL] Oh, is there a reference number?
[AGENT][NEUTRAL] You would use my name along with today's date.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Well, you're very welcome. So again, thank you for calling APO and I hope you have a great day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you. Bye-bye.