AccountId: 011433970860
ContactId: c060ee5a-98f0-4a4e-aeb1-d5eedd6f6c26
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 305369 ms
Total Talk Time (AGENT): 95178 ms
Total Talk Time (CUSTOMER): 130195 ms
Interruptions: 1
Overall Sentiment: AGENT=-0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/c060ee5a-98f0-4a4e-aeb1-d5eedd6f6c26_20250428T15:27_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] calling from Ulster Medical Group. I have one client which is denied, so I need additional information regarding on this claim. Before I continue, this call may be recorded for the, yeah, this call may be recorded for the quality and training purpose. Can I continue though?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Of course, yes, and I can get clarification on that claim for you. I'm sorry, what did you say your name was?
[CUSTOMER][NEUTRAL] [PII] May I know your good name, please?
[AGENT][NEUTRAL] It's [PII]
[AGENT][NEUTRAL] And I mean, can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] Yeah, sure, [PII]. There is no action direct line.
[AGENT][NEUTRAL] Thank you. And then do you have the uh policy number?
[CUSTOMER][NEUTRAL] Mm, just give me a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Can I go with the claim number?
[AGENT][NEUTRAL] Uh, sure, yeah, you can give me the claim number.
[CUSTOMER][NEUTRAL] 351-742-0
[AGENT][NEUTRAL] OK thank you one moment please.
[AGENT][NEUTRAL] OK and then uh what was the name and date of birth, uh, for this member please?
[CUSTOMER][NEUTRAL] Yeah, sure. The first name was [PII] and the last name was [PII].
[CUSTOMER][NEUTRAL] And the date of birth was [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that. Alrighty, give me just a moment, let me take a look at this claim.
[AGENT][NEUTRAL] OK, so we were unable to pay a benefit for this claim, [PII], as the uh benefit for the calendar year had been met.
[CUSTOMER][NEUTRAL] Uh, calendar has been Maxa.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, just give me, uh, let me confirm. Uh, is the both, uh, OK. May I know the dollar amount or the visits?
[AGENT][NEUTRAL] Sure
[AGENT][NEUTRAL] It is the dollar amount.
[CUSTOMER][NEUTRAL] OK. May I know the dollar amount for this member?
[AGENT][NEUTRAL] Per calendar year it is $2000.
[CUSTOMER][NEUTRAL] OK, uh, when was the last met, uh, $2000 last met date of service and, uh, is the provider the same or different?
[AGENT][NEGATIVE] Oh, I'm unable to give that information to as that would be through a different provider. It had been met prior to this day though.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh, could you provide the date of service?
[AGENT][NEUTRAL] Uh, for this claim?
[CUSTOMER][NEUTRAL] No, no, no, not this kind. Um, when was the last met to the dollar amount in which claim number you if you have the claim number, uh, last one, the, um, provide, or is there any?
[AGENT][NEGATIVE] Um, I'm unable to give that information, [PII], as that is through a different provider.
[CUSTOMER][NEUTRAL] OK, you have any provider NPA number?
[AGENT][NEUTRAL] You mean for the last claim that was paid for this number?
[CUSTOMER][NEUTRAL] Yeah, when was the $2000 met on the date of service that provider MPA.
[AGENT][NEGATIVE] Yeah, I'm unable to give that information [PII] as that is through a different career than this one.
[CUSTOMER][NEUTRAL] OK, you do, you didn't have the information about the when was the last met and uh when was the date of service is not have any details credence of recording on the before before last my date of service.
[AGENT][NEGATIVE] Right, I'm unable to give that information as that is through a different provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, just give me one second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, uh, finally confirm one thing is the dollar amount $2000 was met, so it was denied as a non-covered, is correct?
[AGENT][NEUTRAL] Correct, because we were unable to uh pay anything additional.
[CUSTOMER][NEUTRAL] OK, can I go for the patient responsibility for the balance amount?
[AGENT][NEUTRAL] We don't say what is patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] Oh, that would be up to the provider only.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] I mean, is the bill patient, uh, can I go for the bill patient or can go for the provider side?
[AGENT][NEUTRAL] That would be up to the provider we don't say what is or is not patient responsibility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, could you provide the call reference number for this one?
[AGENT][NEUTRAL] Sure, that would just be my first name, last initial, and today's date. Uh, so my last initial is [PII], was there anything else I could help you with, [PII]?
[CUSTOMER][POSITIVE] Uh, that's it from my side, [PII]. Have a great day. Bye bye.
[AGENT][POSITIVE] All right, yeah, thanks for giving us a call. You too. Bye-bye.
[CUSTOMER][NEUTRAL] OK.