AccountId: 011433970860
ContactId: bfeae00d-445c-40da-a80e-b571c825b82f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 374929 ms
Total Talk Time (AGENT): 132332 ms
Total Talk Time (CUSTOMER): 106952 ms
Interruptions: 0
Overall Sentiment: AGENT=2, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/bfeae00d-445c-40da-a80e-b571c825b82f_20250207T16:18_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, uh, my name is [PII] calling from provider's office, and, uh, I do have a special question now regarding the claim. Could you assist me?
[AGENT][POSITIVE] It would be my pleasure to assist you with that claim information, [PII]. What is the callback number?
[CUSTOMER][NEUTRAL] Sure, callback number is [PII].
[AGENT][NEUTRAL] Thank you, [PII]. And what is the claim number? Do you have that available?
[CUSTOMER][NEUTRAL] Mm, one moment.
[CUSTOMER][NEUTRAL] Claim number is 352.
[CUSTOMER][NEUTRAL] 682-2.
[AGENT][NEUTRAL] Thank you, [PII] and what is the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Uh yep, sure.
[CUSTOMER][NEUTRAL] Patient's name is uh [PII]. Date of birth is [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] And what was that data service bill amount and provider name, please?
[CUSTOMER][NEUTRAL] Mm sure.
[CUSTOMER][NEUTRAL] Day of services 100 [PII]. The amount is $424.72.
[CUSTOMER][NEUTRAL] And the facility name is uh Johann Lam Dermatology.
[AGENT][POSITIVE] Alright thank you and it would be my pleasure to assist you with that claim status or claim information. I do have the claim pulled up. How can I help you?
[CUSTOMER][NEUTRAL] Actually, the claim got denied, so could you please tell me the exact reason.
[AGENT][POSITIVE] All right, I can help you with that.
[AGENT][NEUTRAL] Now for the.
[AGENT][NEUTRAL] CPT 99214 that was denied as the patient's policy does not provide benefits for the office visit.
[CUSTOMER][NEUTRAL] OK. And what about the CBD 110, I'm sorry, 11,300.
[AGENT][NEUTRAL] Yes, sir. Now that uh procedures or treatments are covered in a doctor's office, however,
[AGENT][NEUTRAL] When we received this claim, the outpatient benefit for the calendar year has been met. Benefits for procedures or treatments in the office are covered under that outpatient benefit.
[CUSTOMER][NEUTRAL] Um, you mean the maximum benefits was exceed, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Um, in terms of dollars or in terms of visits.
[AGENT][NEUTRAL] It is a dollar amount of $1000 per calendar year. Now that is a verification of coverage and not a guarantee of payment.
[CUSTOMER][NEUTRAL] So the member has already accumulated the $1000 a month, right?
[AGENT][NEUTRAL] That is correct. Therefore, no benefits were payable.
[CUSTOMER][NEUTRAL] Um, we know that that date of service, uh, I mean, the, when the patient was fully accumulated the $1000 amount?
[AGENT][NEUTRAL] Now that was paid on [PII].
[AGENT][NEUTRAL] For data service 8:13 which was prior to your claim.
[CUSTOMER][NEUTRAL] You said the data service is 8:[PII], right?
[AGENT][NEUTRAL] 8:13.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Oh, OK, one moment.
[CUSTOMER][NEUTRAL] Could you please confirm the maximum benefits fully accumulated on the date of services [PII] right?
[AGENT][NEUTRAL] That's correct. [PII].
[CUSTOMER][NEUTRAL] No, no, OK.
[CUSTOMER][NEUTRAL] And the eligible amount for the year is $1000 right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Thank you. And uh could you please tell me the plan name?
[AGENT][NEUTRAL] It is a Medlink gap policy.
[CUSTOMER][NEUTRAL] Matin gap right.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And for the date of service, I mean the 8-132024 under the, under this um under this uh same provider or a different provider?
[AGENT][NEUTRAL] It's a different provider. I'm unable to disclose any other information regarding the claim.
[CUSTOMER][NEUTRAL] Oh, OK. And uh could you please tell me the claim is process date? I mean, the state of service [PII].
[AGENT][NEUTRAL] The claim was processed on received on [PII] and processed on [PII].
[CUSTOMER][POSITIVE] Thank you. And uh could you please spell your name?
[AGENT][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] And [PII], if you need a reference number, it would be my name in today's date.
[AGENT][NEUTRAL] Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][POSITIVE] Mm, no. Thank you so much.
[AGENT][POSITIVE] And thank you for calling APL. It's been a pleasure to assist you with that claim information, [PII]. Have a wonderful afternoon and a happy weekend.
[CUSTOMER][POSITIVE] OK, take care. Bye-bye.
[AGENT][POSITIVE] Thank you bye bye.