AccountId: 011433970860
ContactId: c5177c78-6c1d-47b3-bbd6-6cff5530eb94
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 243250 ms
Total Talk Time (AGENT): 96668 ms
Total Talk Time (CUSTOMER): 78134 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/31/c5177c78-6c1d-47b3-bbd6-6cff5530eb94_20241231T17:04_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah, hi, good afternoon. My name is [PII] and I'm calling from provider's office to check on claim status.
[AGENT][NEUTRAL] May I have a callback number please?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] It's a direct line.
[AGENT][NEUTRAL] And may I have the policy number?
[CUSTOMER][NEUTRAL] It's 01780658 M as in Mike, L as in Lima, number 8.
[AGENT][NEUTRAL] May I have the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] And you're calling in for status of claim. May I please have the date of service and total bill?
[CUSTOMER][NEUTRAL] It's [PII] and the total bill amount is $1000 even.
[AGENT][NEUTRAL] And was that 111 or 114?
[CUSTOMER][NEUTRAL] 111.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] And I'm pulling that information up for you now.
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] And for that claim, it does show that we received it on 129-24.
[AGENT][NEUTRAL] It was processed on [PII].
[AGENT][NEUTRAL] That claim number is 353.
[AGENT][NEUTRAL] 9551 that claim processed and it denied that the per calendar year max had been met.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] But, and how much is the dollar amount per calendar year?
[AGENT][NEUTRAL] Let me pull that up for you.
[CUSTOMER][NEUTRAL] Max
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] And for the calendar year verification of coverage does not guarantee the payment of the claim. The member has up to $2500 per calendar year.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] But in this calendar year, we have not received that much of account from the patient.
[CUSTOMER][NEUTRAL] Or from the insurance.
[AGENT][NEUTRAL] If the member has other claims that came in for the year of [PII] and that maximum amount had been paid out, that member had no available benefits for that date of service.
[CUSTOMER][NEUTRAL] Yes. But for our provider, uh, we didn't receive that much of payment.
[AGENT][NEUTRAL] OK, but it has nothing to do with your provider if there's other claims that's been received, if that maximum amount has been used, the member has exhausted their benefits for that year.
[CUSTOMER][NEUTRAL] Yes, but what about us? We didn't receive any payment. So what is our fault?
[AGENT][NEUTRAL] It has nothing to do with fault. The member has no other benefits available.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But I think this should claim should reprocess because our provider should receive the payment.
[AGENT][NEUTRAL] The provider can't receive a payment if the member does not have any benefits available.
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] If they've already exhausted their benefits, we can't pay anything else out for the year.
[CUSTOMER][NEUTRAL] But they have not exhausted with our doctor.
[AGENT][NEGATIVE] They have exhausted with us.
[AGENT][NEUTRAL] We have paid out the maximum amount that we can pay out for this member.
[CUSTOMER][POSITIVE] OK, fine. OK, fine. Thank you so much. Thank you for your assistance. Have a great day. Bye for now.
[AGENT][POSITIVE] Thank you for calling American Public Life. Have a great day as well.