AccountId: 011433970860
ContactId: c96008c3-3464-44e5-a775-5c6e6dde30db
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1061040 ms
Total Talk Time (AGENT): 299976 ms
Total Talk Time (CUSTOMER): 236898 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/c96008c3-3464-44e5-a775-5c6e6dde30db_20250604T15:36_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, this is [PII] calling from Skin and Cancer Associates. How are you doing today?
[AGENT][POSITIVE] I'm doing well. How are you?
[CUSTOMER][POSITIVE] I'm also doing good, thank you for asking. And I'm calling to check the claim status.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and how many claims in total do you have today, so low?
[CUSTOMER][NEUTRAL] I have 2 claims to check the status.
[AGENT][NEUTRAL] OK, may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, before I proceed with that, please be informed that this call has been recorded for quality and training purpose. Would you like us to continue the recording?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] Yes, thank you, [PII]. And
[CUSTOMER][NEUTRAL] My good callback number is [PII] and it is a direct line.
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh, before I proceed with the member's policy number, may I know your last name initial, please?
[AGENT][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] Yes, thank you, [PII]. Thank you for that. And the patient's member ID policy number is 008199917.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, so that's not an APL policy number. Um, do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, what's the member's first and last name?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh, member's first name is [PII].
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Last name is [PII]
[CUSTOMER][POSITIVE] Yes, that is right.
[AGENT][NEUTRAL] OK. I just want to make sure because I'm not showing a policy with that last name. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, I'm not showing a policy here with this member's name.
[AGENT][NEUTRAL] Are they the policyholder?
[CUSTOMER][NEGATIVE] Not showing any policy please.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] I is [PII] the policyholder on the policy or is she a spouse or dependent?
[CUSTOMER][NEUTRAL] Mm, no, as per our records, no, she, uh, she's only the actual policyholder.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm just making sure because if she was, it could be in somebody else's name. So we don't have a policy with her name um on it, and that policy number provided is not an APL policy number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, uh, is there any option? Can you check with the, uh, SSN, last four digits of the SSN number?
[AGENT][NEUTRAL] Um, in order to search with the social, it need to be the full social.
[CUSTOMER][NEUTRAL] You need the full social security number?
[AGENT][NEUTRAL] Yes, to to search for a policy, yes, I need the full social.
[CUSTOMER][NEUTRAL] OK. But we don't have the full Social Security number. We have only last four digits of the SSN.
[AGENT][NEUTRAL] OK, so you'll have to get more information from the insured in reference to their insurance, um, if you need to get a copy of the card maybe, um, but with the policy number listed or the policy number given, the first and last name given, nothing matches that and we can search with the social, but it would need to be the full social.
[CUSTOMER][NEUTRAL] Full social.
[AGENT][NEUTRAL] Did you want to move to the next claim?
[AGENT][NEUTRAL] Or is it for the same person?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] No, the other person. Please wait for a moment. I'm pulling out the number.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK. Yes. The, another members.
[CUSTOMER][NEUTRAL] Policy number is
[CUSTOMER][NEUTRAL] It is 01659528 M as in Mary, L as in Lima, and number 8.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes. Uh, member's first name is [PII]. It's spelled as [PII], and the last name is [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service and the total bill for the claim?
[CUSTOMER][NEUTRAL] The date of service is [PII] and the total bill amount is $277 even.
[AGENT][NEUTRAL] Thank you, and all the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment while I locate the claim for you.
[AGENT][NEUTRAL] So we received this claim 3 times. Are you wanting the original or did you need all 3?
[CUSTOMER][NEUTRAL] Uh, I need the original claim status.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim? Would it be the skin and cancer?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the claim was received on [PII]?
[AGENT][NEUTRAL] The claim number is 34[PII].
[AGENT][NEUTRAL] In August, on [PII], the claim was processed.
[AGENT][NEGATIVE] It was denied because the uh maximum for a calendar year has been met.
[AGENT][NEUTRAL] So there are no office visits payable by the policy until next year, the next calendar year.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yes, uh, sorry for that. Uh, as you mentioned that maximum benefits existed, uh, has this exceeded in the terms of visits, dollars, or units?
[AGENT][NEUTRAL] Visits.
[CUSTOMER][NEUTRAL] Visits. So, how many total visits are covered in the calendar year for this patient?
[AGENT][NEUTRAL] 4 office visits per year.
[CUSTOMER][NEUTRAL] For office visits. But as for our record, we see that this is the first office visit. Then why it was denied, may I know?
[AGENT][NEUTRAL] That you submitted.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] But there's other claims here that we paid out on that exhausted the four office visits before your claim came in.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For, for the, those claims are for the different provider or for the same provider?
[AGENT][NEUTRAL] Let me see if they're the same. Hold on one second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, do you mind if I place you on just a brief hold while I go through this?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] It doesn't matter. This is how I know this is.
[AGENT][NEGATIVE] Real providers, they brought this real providers ain't gonna ask that cause it don't matter.
[AGENT][NEUTRAL] Somebody that brought a file um.
[AGENT][NEUTRAL] It's claim number 3417647.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Hmm.
[AGENT][NEUTRAL] Wait, while I'm putting that, I need to make sure.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] These are two different calendar years.
[AGENT][POSITIVE] Alright, that's what we're gonna do. I think it's an easier way to do this. Hold on, let me just stop.
[AGENT][NEUTRAL] And to do that.
[AGENT][POSITIVE] It's easier.
[AGENT][NEUTRAL] When's the data server 2024.
[AGENT][NEUTRAL] No, that's not gonna show it, so I'm gonna have to do it like this.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I got 3. I only got 2 right here. What's this.
[AGENT][NEUTRAL] Um [PII] anyway.
[AGENT][NEUTRAL] It's different calendar year, so I mean.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] What's the policy? Cause this is ridiculous. I shouldn't even have to do this. Why are they asking us?
[AGENT][NEUTRAL] Doesn't it doesn't matter.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, so it's gonna say that.
[AGENT][NEUTRAL] Hello [PII].
[AGENT][POSITIVE] Thank you so much for holding. Hello.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you so much for holding. So yes, one of the claims was um did belong to your provider, the other did not. Um, did you want the claim that that belonged to you or you just want to know how it was exhausted?
[CUSTOMER][NEUTRAL] Uh yes, we need, uh, for this, for our provider. Can you please
[CUSTOMER][NEUTRAL] Provide us details.
[AGENT][NEUTRAL] I don't, you're wanting to know the details of the claim that we paid out using this benefit on?
[CUSTOMER][NEUTRAL] Yes, we need that information which belongs to our.
[AGENT][NEUTRAL] Why
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] Why do you need that information? By the time your claim came in, the benefit was exhausted.
[AGENT][NEUTRAL] I can give you the claim that pertains to your provider, but there was only one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] There's a
[CUSTOMER][POSITIVE] Yes, I know that I need.
[AGENT][NEUTRAL] So the claim number is 342-4789.
[CUSTOMER][NEUTRAL] And what is the date of service for that?
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Yes, sir. Thank you, [PII]. Thank you for your information.
[CUSTOMER][NEUTRAL] And can I get the call reference for this number?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] No, so there's no call reference number, but you can use my name in today's date, um, and the first initial again is [PII] to my last name.
[CUSTOMER][POSITIVE] Thank you, [PII]. Thank you for your information and have a nice day. Bye for now.
[AGENT][POSITIVE] You also so thanks for calling APL. Bye-bye.