AccountId: 011433970860
ContactId: d8b309ac-5dd6-4deb-82ff-6ec9c28d766d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 427779 ms
Total Talk Time (AGENT): 147798 ms
Total Talk Time (CUSTOMER): 118284 ms
Interruptions: 0
Overall Sentiment: AGENT=1.4, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/04/d8b309ac-5dd6-4deb-82ff-6ec9c28d766d_20250304T19:19_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling from provider office looking for claim status.
[AGENT][NEUTRAL] OK, [PII], you're needing claim status, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, I can help you with that, [PII]. And what is your callback number, please?
[CUSTOMER][NEUTRAL] Uh, callback number is [PII].
[AGENT][NEUTRAL] Thank you and [PII], how many points do you have to check status on today?
[CUSTOMER][NEUTRAL] Mm, I do have one I think like one only.
[AGENT][NEUTRAL] OK. And what is that patient's policy number?
[CUSTOMER][NEUTRAL] That is 01863350.
[AGENT][NEUTRAL] I'm sorry, [PII], can you repeat it? The noise in the background. I wasn't able to understand what you said.
[CUSTOMER][NEUTRAL] Oh yes.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I'm sorry for that. And the policy number is 01863350.
[AGENT][NEUTRAL] OK, thank you. One moment please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And here, any information that I do provide for you today would be a verification of benefits.
[CUSTOMER][NEUTRAL] Uh, mhm.
[AGENT][NEUTRAL] That's not a guarantee
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hello [PII], can you hear me?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes, I, I can hear you now. Your voice is breaking. I miss that.
[AGENT][NEUTRAL] What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] The patient name is uh [PII]. [PII].
[AGENT][NEUTRAL] Uh
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And what is the date of service and total bill amount for her, please?
[CUSTOMER][NEUTRAL] Um, data service is [PII] bill amount $254.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so this claim was received on [PII].
[AGENT][NEUTRAL] Process on 925-2024.
[AGENT][NEUTRAL] The claim number is 350.
[AGENT][NEUTRAL] 9944.
[AGENT][NEUTRAL] And [PII], this claim was denied, and the reason for the denial on the claim states the calendar year maximum for outpatient office visits due to sickness and or accident has been met for this calendar year.
[CUSTOMER][NEUTRAL] Uh, could you repeat that another reason and you're saying that, um, maximum benefit raised?
[AGENT][NEUTRAL] That is correct. The exact remark states calendar year maximum.
[CUSTOMER][NEUTRAL] In terms of
[AGENT][NEUTRAL] For outpatient office visits?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Due to sickness?
[AGENT][NEUTRAL] And or accident.
[AGENT][NEUTRAL] Has been meant for this calendar year.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So, what was the limit?
[AGENT][NEUTRAL] 4 visits per calendar year.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] 4 digits.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEGATIVE] Limit was 4 visits and when, when did this, these benefits were exhausted?
[AGENT][NEUTRAL] One moment, [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And it was for another claim processed on the same day prior to yours.
[CUSTOMER][NEUTRAL] But the all 4 visits have been done on this calendar year.
[AGENT][POSITIVE] That is correct, yes sir.
[CUSTOMER][NEUTRAL] Do do you have those data services by any chance?
[AGENT][NEUTRAL] No, sir. I can't provide another provider's claims information to you.
[CUSTOMER][NEUTRAL] Those are for different providers?
[AGENT][NEUTRAL] Yes, uh yes.
[CUSTOMER][NEUTRAL] Mm, so, is it based responsibility?
[AGENT][NEUTRAL] We do not determine patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] But this is benefit adjuster for this patient, right?
[AGENT][NEUTRAL] We got a major.
[AGENT][NEUTRAL] We are not a major medical insurance company and we do not determine patient responsibility, that would be up to the provider.
[CUSTOMER][NEUTRAL] But this is uh not code under member plan, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Is there any provider discount?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] For any questions related to discount you would have to reach out to Multiplan who is the network provider for this.
[CUSTOMER][NEUTRAL] Oh, OK, and the claim number is 3509944.
[AGENT][NEUTRAL] Member.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Call reference number?
[AGENT][NEUTRAL] Again, as I explained before, you would use my name along with today's date.
[CUSTOMER][NEUTRAL] What is your name?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII], uh, today's date. OK, thank you very much, [PII].
[AGENT][POSITIVE] Mhm, that's good.
[AGENT][POSITIVE] Alright, you're welcome, [PII]. So is there anything else I can help you with?
[CUSTOMER][POSITIVE] I'm just I about you thank you very much have a nice one.
[AGENT][POSITIVE] OK. Well, I hope you have a nice afternoon as well, and thank you again for calling APL.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Bye-bye.