AccountId: 011433970860
ContactId: bb87675a-1793-415d-b64c-958b30cd8c7a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 425720 ms
Total Talk Time (AGENT): 154091 ms
Total Talk Time (CUSTOMER): 106281 ms
Interruptions: 0
Overall Sentiment: AGENT=1.4, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/bb87675a-1793-415d-b64c-958b30cd8c7a_20250429T14:52_UTC.wav
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[AGENT][NEUTRAL] And thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from provider's office and claim status.
[AGENT][NEUTRAL] OK, you're needing to check claim status, is that correct?
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK, yes, I can help you with that, and I'm sorry, what was your name?
[CUSTOMER][NEUTRAL] It's [PII]
[AGENT][NEUTRAL] Thank you and [PII], what is your callback number?
[CUSTOMER][NEUTRAL] Callback number is [PII].
[AGENT][NEUTRAL] Thank you and you have one claim, is that correct?
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK. And what is that member's policy number, please?
[CUSTOMER][NEUTRAL] Uh, sure, the member's ID here, it's um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 02510235
[AGENT][NEUTRAL] OK, did you say 0251?
[CUSTOMER][NEUTRAL] Yes, 02510235.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me get the information, um, excuse me, the member's information pulled up please.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] In regard to any information that I do provide for you today would be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure. The patient's name is [PII].
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And what is the date of service and total bill amount for her place?
[CUSTOMER][NEUTRAL] Yes, sir. It's [PII] and that's for $460 even.
[AGENT][NEUTRAL] And you did say data services [PII], is that correct?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so this claim has been received multiple times. The most recent claim was denied as a duplicate. Are you needing the original claims information?
[CUSTOMER][NEUTRAL] Yes, can I know the original claims information?
[AGENT][NEUTRAL] Hey, the original claim was received on 10-9-2024.
[AGENT][NEUTRAL] It was processed on 10-15-2024.
[AGENT][NEUTRAL] The claim number Ricardo is 351.
[AGENT][NEUTRAL] 7359.
[AGENT][NEUTRAL] And this claim was denied?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And just one moment and I'll provide you that information.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so the reason for the denial on here for code 99385.
[AGENT][NEUTRAL] Was the calendar year maximum?
[AGENT][NEUTRAL] For the wellness benefit has been met for this calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And for code 36415.
[AGENT][NEUTRAL] The remark states via puncture.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] is not covered by this policy.
[CUSTOMER][NEUTRAL] OK. OK. So, can I know when was the uh
[CUSTOMER][POSITIVE] Benefit me last.
[CUSTOMER][NEUTRAL] Maybe
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] It was met on for the same data service with another claim that was processed prior to yours and I can't provide that information.
[AGENT][NEUTRAL] Because it was for another provider.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And if you need a copy of this explanation of benefits, [PII], you should be able to print that from our portal by going to secured. [PII].
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, and can I know as per patients plan how many visits are allowed per calendar year? I mean, wellness visits?
[AGENT][NEUTRAL] Well this is it's one.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh so this is patient responsibility, right?
[AGENT][NEUTRAL] We do not determine patient responsibility, that would be up to the provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And um
[CUSTOMER][NEUTRAL] Can I know the reference number?
[AGENT][NEUTRAL] Yes sir, you would use my name that I gave you along with today's date.
[CUSTOMER][POSITIVE] OK, [PII], thanks so much for that information provided. Have a great rest of the day.
[AGENT][POSITIVE] Well, you're very welcome.
[AGENT][POSITIVE] OK. Well, I hope you do too. And is there anything else that I could help you with this morning, [PII]?
[CUSTOMER][POSITIVE] No, that's it for the day. Thank you so much.
[AGENT][POSITIVE] OK. Well, thank you. You're welcome and thank you again for calling APO. I hope you have a great day.
[CUSTOMER][POSITIVE] You too. Take care, stay safe. Bye-bye.
[AGENT][POSITIVE] Thank you. Uh-huh. Bye-bye.