AccountId: 011433970860
ContactId: cc51b588-d016-4166-b3cf-4a95468ea785
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 483160 ms
Total Talk Time (AGENT): 138418 ms
Total Talk Time (CUSTOMER): 118068 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/21/cc51b588-d016-4166-b3cf-4a95468ea785_20250321T16:29_UTC.wav
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[AGENT][POSITIVE] Good morning thank you for calling APL my name is how may I help you?
[CUSTOMER][NEUTRAL] Hi, I'm calling to check on the status of some claims please for a patient.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status and may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII] [PII] and what was your first name again?
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome. And [PII], may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, it is 02566221.
[CUSTOMER][NEUTRAL] It's not coming up on the portal so I'm not sure.
[AGENT][NEUTRAL] OK, you said 0256621?
[CUSTOMER][NEUTRAL] 662-21.
[AGENT][NEUTRAL] 221. OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bill for the claim?
[CUSTOMER][NEUTRAL] 35 [PII] and then let me get you the total.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Looks like it's $18.18.
[CUSTOMER][NEGATIVE] It's stating the maximum maximum payment has already been received, but we haven't received the payment yet.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] So I just located the claim and I'm looking at the reason now.
[CUSTOMER][NEUTRAL] It's kind of funny because on the EOB it says under services minor diagnostic exam but it's it's labs. I don't know if that's still considered exam in the payers' eyes, but curious.
[AGENT][NEUTRAL] OK. Um, do you mind if I place you on just a brief hold while I take a look at the claim?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Alright, hold on one moment. You're welcome.
[CUSTOMER][POSITIVE] That's fine thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] It looks like it's saying.
[AGENT][NEUTRAL] 2 days for a calendar year will pay $100 towards the uh.
[AGENT][NEUTRAL] Never seen it, so I just wanna make sure.
[AGENT][POSITIVE] OK, I was right. OK.
[AGENT][NEUTRAL] Some water.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, [PII]?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. So there's, so basically, the claim that you received is giving that denial reason because there was a claim that came in also on that data service that paid out the $100. So the benefit is $100 per day with a max of 3 days per calendar year. So we received multiple um Go ahead.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And this is
[CUSTOMER][NEUTRAL] Go ahead, no, no, go ahead, I'm sorry.
[AGENT][NEUTRAL] It's OK. We received multiple claims for um for your date of service, but it was paid, the $100 was paid out to the first claim that came in for that date of service.
[CUSTOMER][NEUTRAL] OK, so I'm, yeah, OK, so I see 3 data 3 claims from that same data service. OK, so let me just pull up this other one here. OK, those are laps too, so for.
[AGENT][NEUTRAL] So the one that it was paid out on was the.
[AGENT][NEUTRAL] Claim number 357-4412.
[CUSTOMER][NEUTRAL] Uh, let me look at the EOB here.
[CUSTOMER][NEUTRAL] Yes, correct. OK, so she, so for labs she's only allowed to have like, right, so $100 for lab, so she's only allowed a $100 max for lab or is this for any kind of services?
[AGENT][NEUTRAL] So, so that's why the other two received that.
[AGENT][NEUTRAL] No, this particular minor diagnostic exam benefit, um, that's the benefit particular to it, $100 per day with a max of 3 days per calendar year.
[CUSTOMER][NEUTRAL] OK, now do you.
[CUSTOMER][NEUTRAL] The other two claims that are being denied because of course that because the payment's already been received um are we permitted to build the patient for the for those then or do we still have to accept the contractual adjustment, do you know?
[AGENT][NEUTRAL] Well, we don't determine patient responsibility at APL because we're not a major medical insurance company, um, so it'll be whatever your process is for remaining outstanding balances.
[CUSTOMER][NEUTRAL] Yeah, I was gonna say because on the EOB it doesn't really state patient responsibility it just states the max payment, OK.
[AGENT][NEUTRAL] Right, mhm, because we can't determine it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Sure, OK, so then I don't have to ask you about the other two dates since you answered that for me. OK, perfect. OK, that's actually all I, that's all I needed. Can I get a reference number for our call, and I appreciate your help.
[AGENT][NEUTRAL] You're very welcome. There's no call reference number, but you can use my name in today's date. And again, that's [PII], first initial to my last name, [PII].
[CUSTOMER][POSITIVE] Perfect thank you have a good weekend.
[AGENT][POSITIVE] You're welcome, [PII], and thanks for calling APLU also. Bye-bye.
[CUSTOMER][POSITIVE] Thank you bye bye.