AccountId: 011433970860
ContactId: bcafa857-7c80-474e-9528-1380f300be1e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 537979 ms
Total Talk Time (AGENT): 174593 ms
Total Talk Time (CUSTOMER): 236117 ms
Interruptions: 8
Overall Sentiment: AGENT=1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/15/bcafa857-7c80-474e-9528-1380f300be1e_20250415T19:17_UTC.wav
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[CUSTOMER][NEUTRAL] I.
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][POSITIVE] Hi [PII], how are you? I'm also good. Thank you for asking. My name is [PII] calling from Osar Medical Center. I need some help regarding to the general claim status.
[AGENT][POSITIVE] I'm doing well. How are you?
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status, [PII], and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I have 2 claims for a single patient.
[AGENT][NEUTRAL] OK, and may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Oh, that's [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] For my first policy number is 02335719.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And are the claims for the same member?
[CUSTOMER][NEUTRAL] Mo
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] The [PII]'s date of birth is [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the dates of service and the total bill for the claim?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] April [PII] bill amount $760 even.
[AGENT][NEUTRAL] OK, and you have another data service?
[CUSTOMER][NEUTRAL] today.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] By another date of service.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] And the total bills?
[CUSTOMER][NEUTRAL] $463 even.
[CUSTOMER][NEUTRAL] Sorry, that's for $93 even.
[AGENT][NEUTRAL] For 93. OK, hold on one moment.
[CUSTOMER][NEUTRAL] 4493, 493, not 193.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claims?
[CUSTOMER][NEUTRAL] The O Medical Center.
[AGENT][NEUTRAL] OK. Hold on one moment.
[CUSTOMER][NEUTRAL] Baton Rouge.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] I'm saying nothing.
[AGENT][NEUTRAL] Alright, so I'm showing we received the claim on [PII].
[AGENT][NEUTRAL] This is for the um [PII] claim.
[AGENT][NEUTRAL] That claim number is 3,454,960.
[AGENT][NEUTRAL] And also on [PII], the claim was denied.
[AGENT][NEUTRAL] Because the calendar year maximum for physical, speech, or occupational therapy has been met.
[CUSTOMER][NEUTRAL] Just wait a second, just wait a second. This claim is for [PII] or [PII]?
[AGENT][NEUTRAL] The one that I just gave was [PII].
[CUSTOMER][NEUTRAL] OK. This claim was received on [PII]. And what's the claim number?
[AGENT][NEUTRAL] 3,454,960.
[CUSTOMER][NEUTRAL] I don't
[CUSTOMER][NEUTRAL] 3,454,960, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] But as for my, it will be my claim number is 7,202,552,584,300.
[AGENT][NEUTRAL] OK, that's not an APL policy number. They may have another insurance, but the claim number that I provided is the claim number for your data service and total bill for APL.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] OK. What's the reason of the name?
[CUSTOMER][NEUTRAL] Maximum benefits existed, right?
[AGENT][POSITIVE] Correct. Mhm.
[CUSTOMER][NEUTRAL] As per visit wise or dollar right?
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Um, the maximum is $1.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And maximum dollar value?
[CUSTOMER][NEUTRAL] How much dollar amount is allowed?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For physical therapy, the policy will pay up to $30.01 time per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] OK, and uh as per calendar there, there is only $30 for a single visit, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. And how much dollar amount has been met excluding this claim?
[AGENT][NEUTRAL] So this the now reason is saying before your claim came in, that benefit was used, it's only one time, so it's, it's one claim prior to yours that the max was paid out.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] That you
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] Mm, can you go with the second one now?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So the second one was also received on [PII] and processed on [PII]. Um, that claim number is 345.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 4959.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this is actually the claim that paid out the $30 for physical therapy.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Did you need the check information?
[CUSTOMER][NEUTRAL] OK. And
[CUSTOMER][NEUTRAL] Yeah, but, uh, actually, my bill amount is this rate, $463 and we get the payment of only $30 and the remaining amount, what should we do with that remaining amount?
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] We don't determine patient responsibility, um, which is why it's not listed on the explanation of benefits. The remaining balance would be up to you as the provider, um, whatever your policies or procedures are on remaining outstanding balances.
[CUSTOMER][NEUTRAL] 1
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] And I
[CUSTOMER][NEUTRAL] OK, and that means you only provide only for $30 and remaining is the patient's responsibility or the provider's responsibility, right?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] We do not determine patient responsibility. We apply based on our policy, which was the max of $30. Anything outstanding would be up to the provider to deem responsibility.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Just hold on a second. I need to mention everything in my notes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you are saying that, yeah, hi, [PII]. You can say that you only pay for $30 but what will we do with the remaining amount? Do you have any update?
[AGENT][NEUTRAL] Hi.
[AGENT][NEUTRAL] As I've stated,
[CUSTOMER][NEGATIVE] How to overturn this denial.
[AGENT][NEUTRAL] We do not determine patient responsibility, so you would have to reach out to your superiors to see how remaining balances are handled.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, thank you. Can you provide me with the call sir?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] Yeah