AccountId: 011433970860
ContactId: bcc3571e-9eb0-4509-aa06-02c28f6d0aca
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 636340 ms
Total Talk Time (AGENT): 238659 ms
Total Talk Time (CUSTOMER): 117053 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/bcc3571e-9eb0-4509-aa06-02c28f6d0aca_20250103T14:59_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from office to check on a claim status. Could you please assist me?
[AGENT][POSITIVE] Sure, I'll be more than happy to help you with the claim status, [PII]. And how many claims in total do you have today?
[CUSTOMER][NEUTRAL] I have only one thing.
[AGENT][NEUTRAL] OK, may I have a good contact number in case we're disconnected and the member's policy number?
[CUSTOMER][NEUTRAL] Yes, um,
[CUSTOMER][NEUTRAL] The policy number is D as in Delta 43,730,160.
[AGENT][NEUTRAL] And what's a good callback number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's um [PII].
[CUSTOMER][NEUTRAL] [PII] with extension of [PII].
[AGENT][NEUTRAL] Thank you for that. And do you have a copy of the member's ID card available?
[CUSTOMER][NEGATIVE] Mm no.
[AGENT][NEUTRAL] OK, do you have the member's social?
[CUSTOMER][NEUTRAL] One moment, yes.
[AGENT][NEUTRAL] What's the member's social because that D number is for 90 degree benefits, so we can't use that one.
[CUSTOMER][NEUTRAL] OK, so it's [PII].
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And what is the member's first and last name?
[CUSTOMER][NEUTRAL] It is [PII], and date of birth is [PII].
[AGENT][NEUTRAL] OK, hold on one moment, I'm just waiting for the policies to populate.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And this is for her medical policy or dental or what type of policy?
[CUSTOMER][NEUTRAL] Medical
[AGENT][NEUTRAL] Medical, OK, hold on one moment.
[CUSTOMER][NEUTRAL] Sure
[AGENT][NEUTRAL] All right, and I have the policy here and thank you so much for verifying and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you like me to check on?
[CUSTOMER][NEUTRAL] Yes, it's a it's uh [PII].
[CUSTOMER][NEUTRAL] And uh bill amount is $314 even.
[AGENT][NEUTRAL] 314.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] $314.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yes, it's radiology Associates of Northern Kentucky.
[AGENT][NEUTRAL] OK, here it is.
[AGENT][NEUTRAL] So I'm showing we received the claim on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That claim number is 352.
[AGENT][NEUTRAL] 5890.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Because the calendar year maximum on diagnostic services has been met.
[CUSTOMER][NEUTRAL] Diagnostic service maximum has been met, right?
[AGENT][NEUTRAL] Yes, for the calendar year.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK. How much is the limit and when it was met, ma'am?
[AGENT][NEUTRAL] Um, hold on one moment, I'm pulling that up for you now.
[AGENT][NEUTRAL] So the benefit is um up to $75 per visit with a max of 5 visits per calendar year. Um, so, let me see when they met it.
[CUSTOMER][NEUTRAL] So 5 visits per year and uh how much you said the dollar amount per visit? Sure.
[AGENT][NEUTRAL] Actually, hold on one moment, hold on one moment.
[AGENT][NEUTRAL] Because this is for diagnostic.
[AGENT][NEUTRAL] Is it one test?
[AGENT][NEUTRAL] Do you mind if I place you on just a brief hold so I can look at this claim?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, now wait a minute.
[AGENT][NEUTRAL] Diagnostic testing, I mean, diagnostic testing benefit per test 250. There's no limit.
[AGENT][NEUTRAL] Wellness exam or test benefit per test 75.
[AGENT][NEUTRAL] Well, heck, I don't know. Because what, what's the limit for the year?
[AGENT][NEGATIVE] There is no limit. It's per test. Uh oh, I think we messed up.
[AGENT][NEUTRAL] Wait,
[AGENT][NEUTRAL] They use the wellness diagnostic benefit rider. Wait, that's this.
[AGENT][NEUTRAL] Oh, no, no, no, no, no. I'm sorry. I'm calling claims.
[AGENT][NEUTRAL] I'm not waiting 20 minutes.
[AGENT][NEUTRAL] Oh, what do I do? Oh, she said to start on the [PII], so I'm calling them.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Certainly no agent staffed. Goodbye.
[AGENT][POSITIVE] Alrighty then, let me get to these chats. I mean, that's all I could do.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Oh,
[AGENT][POSITIVE] There's some benefits is that, OK, I got it now.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am. Yes.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So the max for the diagnostic testing benefit is $250 per calendar year.
[AGENT][NEUTRAL] And this was applied to a previous claim.
[AGENT][NEUTRAL] Um, but it's a different provider, so I can't give that claim information.
[CUSTOMER][NEUTRAL] OK, so limit is 5 visits per year, also 250.
[AGENT][NEGATIVE] No, no, no, you can, you can disregard that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Just the $250 per diagnostic test and the max per calendar year is $250.
[CUSTOMER][NEUTRAL] So I
[CUSTOMER][NEUTRAL] And it's already
[CUSTOMER][NEGATIVE] Pay to another different provider.
[AGENT][NEUTRAL] Yes, it was paid to another provider before your claim came in.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you. So in this case, ma'am.
[AGENT][POSITIVE] You're very welcome.
[CUSTOMER][NEUTRAL] May I know the
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] A bill address please.
[AGENT][NEUTRAL] Oh, sure. Um, so our, well, hold on one second.
[AGENT][NEUTRAL] I think this goes to IMA. So you would send thee to [PII]?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] How much is the term following limit to send an app?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] How much is the timely filing limit to send an appeal?
[AGENT][NEUTRAL] You have 180 days from the denial date?
[CUSTOMER][NEUTRAL] Date of denial, which is [PII]. OK. Thank you. And uh could you please spell out your name? [PII], right? [PII]
[AGENT][NEUTRAL] Sure, my name is
[AGENT][NEUTRAL] Yes, and the first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] And could you please tell me the call reference number?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name in today's date.
[AGENT][NEUTRAL] And the first initial, oh I already gave it to you, [PII], sorry.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][POSITIVE] OK, thank you, thank you for assistance. Have a great day.
[AGENT][POSITIVE] You're welcome, [PII]. Was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] No, that's all, thank you, bye.
[AGENT][POSITIVE] Alright, well, thanks so much for calling APL and happy [PII] and have a great weekend.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][POSITIVE] Thank