AccountId: 011433970860
ContactId: c243caac-3661-4d02-bb3c-868da712015b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 946039 ms
Total Talk Time (AGENT): 198849 ms
Total Talk Time (CUSTOMER): 150047 ms
Interruptions: 1
Overall Sentiment: AGENT=1.3, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/c243caac-3661-4d02-bb3c-868da712015b_20250429T14:40_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] This is [PII] calling from provider's office. I'm calling to inquire about a claim status. Can I help you on that?
[AGENT][NEUTRAL] Yes, I can help you with claim status today. Do you have the policy number?
[CUSTOMER][NEUTRAL] Yes, I do have the policy number. It's 025165816.
[AGENT][NEUTRAL] So 251.
[AGENT][NEUTRAL] 6
[CUSTOMER][NEUTRAL] 02515816.
[AGENT][NEUTRAL] 2516. What was the rest?
[CUSTOMER][NEUTRAL] 025158516.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Do you have the patient's first and last name?
[CUSTOMER][NEUTRAL] It's [PII]. Date of birth [PII].
[AGENT][NEUTRAL] OK, and then can you spell their first and last name for me, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and then what's a good callback number in case our call gets dropped?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, can you please slow down and repeat that, [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK. And then [PII] date of birth, please?
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And then the date of service and charge amount you're calling for?
[CUSTOMER][NEUTRAL] [PII] charge amount for 92.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] This
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, so I do not see that claim on file for this data service.
[CUSTOMER][NEUTRAL] 3
[CUSTOMER][NEGATIVE] But we have received the payment of $75 but unfortunately I do not have the claim number. The other CPT codes have been denied.
[CUSTOMER][NEUTRAL] Give me a second, please.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Did you like.
[CUSTOMER][NEUTRAL] Can you please check
[CUSTOMER][NEGATIVE] Well, we received pain.
[CUSTOMER][NEUTRAL] And I.
[AGENT][NEUTRAL] Yes, so it looks like he has multiple policies.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let's see, let me double check the other ones really quick.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] That's.
[AGENT][NEUTRAL] And then what provider's office are you calling from?
[CUSTOMER][NEUTRAL] American Family Care.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] It looks like the policy.
[AGENT][NEUTRAL] Number is 251-581-6.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I found a claim on file.
[AGENT][NEUTRAL] Looks like this is for claim 3553612.
[AGENT][NEUTRAL] OK. Yes, so I see that we paid $75.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then what the other ones were denied, let's see.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] OK, so it looks like the other payments were denied because the maximum benefit payable for this state of service has been met.
[CUSTOMER][NEUTRAL] OK. And how many units are allowed?
[AGENT][NEUTRAL] How many, what exactly?
[CUSTOMER][NEUTRAL] How many units are allowed?
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] It just says the maximum benefit payable for the state of service has been met.
[AGENT][NEUTRAL] Let me
[CUSTOMER][NEUTRAL] Yeah, but my uh
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hold on, let me double check and see how much they've used.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] just
[AGENT][NEUTRAL] OK, sorry, let me dig deeper into their policy so I can see exactly what their benefits.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Are payable too.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] I mean, the payment
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] OK. So it looks like outpatient accident and sickness treatment pays $75 per day.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And that's a max of 6 days. So they, so we have already paid the $75 which is why we will pay no more.
[CUSTOMER][NEUTRAL] Can you send it for review once?
[AGENT][NEUTRAL] Yes, you want me to send you the explanation of benefits over?
[CUSTOMER][NEUTRAL] No, can you, I have the you can you send the claim for the process?
[AGENT][NEUTRAL] Yes, so there's no filing limit to submit a claim.
[CUSTOMER][NEUTRAL] No, I would like you to send this claim for uh review because it doesn't make sense that the other CPT codes have been denied for benefit existed and, uh, this is the first time we have built this service for this patient in this year.
[CUSTOMER][NEUTRAL] The, the patient had not visited.
[AGENT][NEUTRAL] So it
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] and
[CUSTOMER][NEUTRAL] 288-770.
[AGENT][NEUTRAL] So if you would like to send an appeal, you can, and I can give you that address.
[CUSTOMER][NEUTRAL] No, you, I would like you to send it for review, uh, clean it as an initial review.
[AGENT][NEUTRAL] OK, let me put you on a brief hold and ask a colleague about this one, OK?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding. Sorry for that hold.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK. Can I please give you a call back? I will submit.
[AGENT][NEUTRAL] A form to our claims department.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And I will give you a call back, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and then the good callback number is [PII].
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] OK. And then what did you say your name was, [PII]?
[CUSTOMER][NEUTRAL] [PII], yes.
[AGENT][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] No.
[AGENT][POSITIVE] OK, thank you, [PII] and I'll give you a call back, OK?
[CUSTOMER][NEUTRAL] And the reference number?
[AGENT][NEUTRAL] The reference number is my first name, [PII], last initial [PII], and then today's date.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Go on.
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][POSITIVE] Yeah, of course. All right, thanks for calling APL.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][POSITIVE] Have a good day. Bye.
[CUSTOMER][NEUTRAL] I.