AccountId: 011433970860
ContactId: b6d30ff2-1901-4475-b14b-668aaf9c72b8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 364510 ms
Total Talk Time (AGENT): 125732 ms
Total Talk Time (CUSTOMER): 87466 ms
Interruptions: 0
Overall Sentiment: AGENT=2, CUSTOMER=1.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/11/b6d30ff2-1901-4475-b14b-668aaf9c72b8_20250611T20:08_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from provider's office.
[AGENT][POSITIVE] Hi [PII], how are you doing today?
[CUSTOMER][POSITIVE] I'm doing good. Thank you for asking. How are you doing today?
[AGENT][POSITIVE] I'm doing well, thanks for asking. And how may I assist you today?
[CUSTOMER][NEUTRAL] I have a patient's information. I just wanted to check the general status of a claim.
[AGENT][POSITIVE] OK, I'll be more than happy to help you with the claim status and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Uh, just one.
[AGENT][NEUTRAL] Alright, may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] It's 013.
[CUSTOMER][NEUTRAL] 066.
[CUSTOMER][NEUTRAL] 81 M as in Mike, L as in Lima, number 8.
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] The first name is [PII] and the last name is
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And the date of birth is on
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that and all the I'm sorry to give the disclaimer. May I have the date of service and the total bills for the claim?
[CUSTOMER][NEUTRAL] The date of service is on.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the total charge amount is $431.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] It's one moment.
[CUSTOMER][NEUTRAL] It's Cleveland Clinic Health Services.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] So we received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 355.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 0515
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied because the outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, could you please repeat the denial reason?
[AGENT][NEUTRAL] The outpatient max has been met for the year.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes, it is, again, the outpatient max.
[AGENT][NEUTRAL] has been met for the calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, give me one moment.
[CUSTOMER][NEUTRAL] Uh, may I know if the patient's deductible has been met?
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] So there's no deductible for this policy. What that means is, so there's a, there's an amount that we can pay out for outpatient benefits. That amount is $2500 per year.
[AGENT][NEUTRAL] So this denial reason is saying by the time your claim came in, the $2500 that we can pay out on claims had already been used. They used all of their money. So there's nothing else for us to pay out for this year. It will restart in January, excuse me, in January.
[CUSTOMER][POSITIVE] OK. Thank you so much. In that case, can we build this?
[CUSTOMER][NEUTRAL] Patient
[AGENT][NEUTRAL] So we don't determine patient responsibility because we are the secondary insurance. Um, any remaining balances or outstanding balances will be up to you as the provider, um, to determine responsibility.
[CUSTOMER][POSITIVE] OK, thank you so much. Can I have the call reference number?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name and today's date, and again, that's [PII].
[CUSTOMER][POSITIVE] OK. Thank you so much. Have a great day.
[AGENT][POSITIVE] You're welcome. Was there anything else I can assist you with today?
[CUSTOMER][POSITIVE] No, thank you so much.
[AGENT][POSITIVE] All right. Thanks for calling APL. Bye-bye.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.