AccountId: 011433970860
ContactId: d83284b2-7dbb-4b68-9974-9eaf4bad5dd8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 271859 ms
Total Talk Time (AGENT): 104163 ms
Total Talk Time (CUSTOMER): 130829 ms
Interruptions: 3
Overall Sentiment: AGENT=0.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/d83284b2-7dbb-4b68-9974-9eaf4bad5dd8_20250103T13:32_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] here and I'm calling from the provider's office and I'm looking for the claim status.
[AGENT][NEUTRAL] I can help you [PII], uh, with the claim status. What's the policy number and a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, our callback number is [PII] and it is a direct line. And the policy number is 1335673 M as in Mary, L as in Lima, number 7.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Thank you and what's the patient's name and date of birth?
[CUSTOMER][NEUTRAL] The patient's name is uh
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that information, [PII] and you said that it's for a claim status?
[CUSTOMER][NEUTRAL] Let.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And what's the date of service in charge?
[CUSTOMER][NEUTRAL] Data service is uh [PII] and the total charge amount is um
[CUSTOMER][NEUTRAL] $1,006 even.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the maximum payable benefit for this data service has been met. I'm showing it was received [PII].
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I'm OK.
[AGENT][NEUTRAL] Processed [PII].
[AGENT][NEUTRAL] Uh, no payment was made for that reason on this claim. Let me know when you're ready for the claim number.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] for that reason.
[CUSTOMER][NEUTRAL] Um, yes, please provide me the claim number.
[AGENT][NEUTRAL] That number is 352-2.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] 676.
[AGENT][NEUTRAL] And did you have any other questions I can help out with today, [PII]?
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Uh yes. Uh, so the claim is denied for the maximum benefits are exhaust, right? For the rate of service, sir, will you please let me know, uh,
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, how much was the allowed to benefit for this member for per day?
[AGENT][NEUTRAL] OK, so the primary ELB that was submitted with the claim should indicate the allowed amount by the primary.
[CUSTOMER][NEUTRAL] it was a
[CUSTOMER][NEUTRAL] the
[AGENT][NEUTRAL] That information is on the primary ELB.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] See
[CUSTOMER][NEUTRAL] So you mean to say that this um
[CUSTOMER][NEUTRAL] Claim is denied because the primary has already made the uh payment more than the secondary allowed.
[AGENT][NEUTRAL] No.
[AGENT][NEGATIVE] The benefit under this policy is exhausted. That's why no payment was made.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] For the allowed amount you would have to look at the primary EOB that was submitted with your claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] To determine what the allowed amount is.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, so here it is showing the allowed amount is $395.55 even.
[AGENT][NEUTRAL] No, that's not what I'm saying if that's what's on the primary EOB that's where you would get that information.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] I'm saying we did not pay anything because the maximum benefit is exhausted.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] So is this uh visit has been exhausted or the dollar value has exhausted?
[AGENT][NEUTRAL] The maximum outpatient benefit is $200 per calendar day. That that benefit is exhausted for this calendar day.
[CUSTOMER][NEUTRAL] $400.
[AGENT][NEUTRAL] And of course that information provided is verification, not a guarantee of payment. Did you have any other questions, [PII]?
[CUSTOMER][NEUTRAL] Uh uh yes, just, just a second. Patient has
[CUSTOMER][POSITIVE] Alrighty.
[CUSTOMER][NEUTRAL] Uh, OK.
[CUSTOMER][NEUTRAL] Um, for this one, could you please provide me the call reference number?
[AGENT][NEUTRAL] My name in today's date, [PII].
[AGENT][NEUTRAL] Oh NYA first initial of my last name is [PII], and you can also check your claim status on our online service center at secured.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][POSITIVE] [PII]. OK. Got it. Thank you so much for helping me out with this one. Thank you.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] You're welcome. If no other questions, [PII], thank you for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Thank you.