AccountId: 011433970860
ContactId: d02b0528-c792-44f4-9c35-f0baab8690ef
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 935440 ms
Total Talk Time (AGENT): 248630 ms
Total Talk Time (CUSTOMER): 207564 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/16/d02b0528-c792-44f4-9c35-f0baab8690ef_20250116T14:34_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] Uh, yeah, hello. My name is [PII]. I'm calling your provider office. But before proceeding, let me inform you that this call has been recorded for quality and training purpose. Are you fine with that?
[AGENT][NEUTRAL] Yes, I'm fine with that. Um, can you repeat your name for me, please?
[CUSTOMER][NEUTRAL] Yeah, it's uh [PII].
[AGENT][NEUTRAL] OK, and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, sure. Uh, it will be [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII] with extension of [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yeah, sure. It is 02475232.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, member's name will be [PII] and the patient date of birth is [PII].
[AGENT][POSITIVE] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And how may I assist you today?
[CUSTOMER][NEUTRAL] Yeah, I want to know actually a claim status for the patient.
[AGENT][NEUTRAL] OK, may I have the date of service for the claim?
[CUSTOMER][NEUTRAL] Yeah, sure. It will be [PII] and the total bill amount is $572 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] And what is the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Uh american Health Network.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] The total bill is
[AGENT][NEUTRAL] Uh sure.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] It's already.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Uh yeah.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So, um, what is the patient account number on the claim?
[CUSTOMER][POSITIVE] Yeah, no problem. Mhm.
[CUSTOMER][NEUTRAL] Uh, yeah, just let me pull it out.
[AGENT][NEUTRAL] OK, I just wanna make sure I'm in the right right claim.
[CUSTOMER][NEUTRAL] Yeah, it, uh, it is.
[CUSTOMER][NEUTRAL] Yeah, sure. It is 0247.
[CUSTOMER][NEUTRAL] 5232.
[AGENT][NEUTRAL] No, no, no, not the account number for APL like the patient account number that came over on the claim form.
[CUSTOMER][NEUTRAL] Yeah, I just, uh, you want to mean that by encounter number, right?
[AGENT][NEUTRAL] What's your tax ID?
[CUSTOMER][NEUTRAL] Yeah, it is, uh, just a second.
[CUSTOMER][NEUTRAL] Yeah, it is [PII] 1.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, so this claim that we have here has a different total bill, but it is your provider. Um, do you want me to give you this claim status?
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] OK, so I'm showing the claim was received on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 346.
[AGENT][NEUTRAL] 5287.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied?
[AGENT][NEUTRAL] Because the benefit maximum for the data service has been met.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh how much benefit is allowed as per plan because it is stated as max.
[AGENT][NEUTRAL] Let me see what the benefit is.
[AGENT][NEUTRAL] So for the physician office, um, the policy would pay up to 4 times per calendar year, $50 and there was another claim that came in with the same date of service, um, and that $50 was applied to that claim.
[CUSTOMER][NEUTRAL] OK. And may I have the claim number for that?
[AGENT][NEUTRAL] Um, I can't give you that claim number because it's not your provider's claim.
[AGENT][NEUTRAL] It does have the same data service though, you know what, let me double check and make sure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] And I'm sorry, yes, this is your provider. That claim number is 344.
[AGENT][NEUTRAL] 6814.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. For the same provider, the maximum benefits are reached, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK. So, healthful plan only 2 times the benefits allowed.
[AGENT][NEGATIVE] Say that one more time, the phone is breaking up. I couldn't hear that part.
[CUSTOMER][NEUTRAL] Uh, actually, I need to know that, uh, how much time for that benefit is allowed?
[AGENT][NEUTRAL] How much time before the benefit is allowed?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] I don't understand what you mean. It's 4 visits per calendar year at $50 so 4 times a year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Four times a year. And uh in, in [PII], how much time the patient I want to know the cost for that date of service.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Actually, I want to know how many times the patient has used the data service for that benefit.
[CUSTOMER][NEUTRAL] As you mentioned, it is uh
[CUSTOMER][NEUTRAL] Then for the same date of service time, right?
[AGENT][NEUTRAL] I don't understand the question. Are you asking me how many of the visits he's used for [PII] or are you asking me how many he's used for that date?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] Yeah, how many are used for [PII]?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yes, sure.
[AGENT][NEUTRAL] So for [PII], only one of the physician office visits were was used.
[CUSTOMER][NEUTRAL] OK. And what is the date for that?
[AGENT][NEUTRAL] Is your date of service, [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure, just let me double check for. OK.
[AGENT][NEUTRAL] It's your claim.
[CUSTOMER][NEUTRAL] Just can you uh hold for a minute just to let me double check from my side.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] Yeah, thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah. Hello, [PII].
[AGENT][NEUTRAL] Yes, I'm here.
[CUSTOMER][NEUTRAL] Yeah, I just want to confirm what type of plan does the patient has.
[AGENT][NEUTRAL] This is their hospital indemnity policy.
[AGENT][NEUTRAL] So it's a limited medical policy?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Limited medical policy.
[AGENT][NEUTRAL] I'm sorry, the phone is really choppy now. I can't hear you anymore. Can you repeat that for me?
[CUSTOMER][NEUTRAL] Yeah, just, I want to know what type of plan does the patient have.
[AGENT][NEUTRAL] OK, it's a hospital indemnity policy.
[CUSTOMER][NEUTRAL] OK. Hospital indemnity.
[CUSTOMER][NEUTRAL] And just to reconfirm on the, as you said previously on previous date of service of the same type, all the different types of CPT are billed and for the claim which I'm calling, they are all ENM codes, office visit codes.
[AGENT][NEUTRAL] Can you repeat that again? It's, it's very choppy. I can't hear you anymore.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Now, can you hear me properly?
[AGENT][NEUTRAL] It's still choppy, but it's better than it was. Can you, can you say what you said again?
[CUSTOMER][NEUTRAL] Yeah, sure. As I mentioned you uh earlier that on previous same date of service, uh services have been used and they're all different uh procedure codes. As I check in my system, they're all office visit code ENM codes.
[CUSTOMER][NEUTRAL] So just to need confirm then uh how can they be it as a maximum benefit rate.
[AGENT][NEUTRAL] OK, wait a minute. So the benefit is $50.04 times a year.
[AGENT][NEUTRAL] The date of service is [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] There are 2 claims for that 1 date of service. So we applied the max, which was $50.
[AGENT][NEUTRAL] One time for that data service, so we can't apply it to both claims because it's one day.
[AGENT][NEUTRAL] So we applied it to the first claim that came through.
[AGENT][NEUTRAL] The first claim was received on [PII]. Your second claim wasn't received until [PII].
[AGENT][NEUTRAL] So that's why the max was paid out. It's saying that the max has been um received because we paid out the full $50 which is that max for that benefit for your date of service.
[CUSTOMER][NEUTRAL] Yeah, I understand right now. Uh, can you give me the call reference number for this?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name in today's date, and that's [PII] to my [PII] name is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. Thank you for all the information today and have a good day.
[AGENT][POSITIVE] You also, and thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Right.