AccountId: 011433970860
ContactId: d8efd4e5-0561-4691-b9e2-c2235a5b6fd2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 718380 ms
Total Talk Time (AGENT): 194294 ms
Total Talk Time (CUSTOMER): 187289 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/20/d8efd4e5-0561-4691-b9e2-c2235a5b6fd2_20250220T22:16_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah, I'm [PII] looking for the claim status.
[AGENT][NEUTRAL] Uh, and may I have a callback number just in case we get disconnected, Mr. [PII]?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] 02433298.
[AGENT][POSITIVE] Thank you. One moment.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, name is?
[CUSTOMER][NEUTRAL] Necessary [PII].
[AGENT][NEUTRAL] What's the date of birth?
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah, date of service is [PII] and the bill amount $48,672.30.
[AGENT][NEUTRAL] OK, and that was [PII], correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, and for future you can check claim status online through our website at [PII]. In one moment, let me pull this ELB.
[CUSTOMER][NEUTRAL] For
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] I'm waiting on the system. One moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And.
[AGENT][NEUTRAL] All right, so it looks like we processed the claim on [PII] and we send a benefit amount of $2,145 to the provider.
[CUSTOMER][NEUTRAL] Uh, what's the process date, [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. Uh, so you did, you did get the UOB we have sent there before?
[AGENT][NEUTRAL] We got the, yes, we got the explanation of benefits that we needed and we reprocessed the claim and we send a benefit of $2,145 with the payment of that check, the maximum for outpatient service has been exhausted.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Benefit of 2000.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] $2,145.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what you have done?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] With the payment of that check, the maximum for outpatient service has been exhausted.
[CUSTOMER][NEUTRAL] OK, maximum patient services exhausted, right?
[AGENT][NEUTRAL] Mhm. Right.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Just a minute. I'm checking.
[AGENT][NEUTRAL] Mhm. Sure.
[CUSTOMER][NEUTRAL] The benefits, uh, is, it is in dollar or visit amounts.
[AGENT][NEUTRAL] Mhm. Yes, let me get the um the benefits pulled up. OK, one moment.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK, uh, thank you very much, uh.
[AGENT][NEUTRAL] OK, so this particular policy had a benefit amount of $3000 per day.
[CUSTOMER][NEUTRAL] OK. No, uh, I want to ask that.
[CUSTOMER][NEUTRAL] The benefits are exhausted, you have to, no?
[AGENT][NEUTRAL] I'm sorry, can you repeat that?
[CUSTOMER][NEUTRAL] Patient patient services are exhausted, no, right?
[AGENT][POSITIVE] Yes, yes, there is a daily benefit on this one. There is an outpatient daily daily benefit. So the daily benefit amount is 3000.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] When we receive this claim or when we process the claim, the benefit has been exhausted with that payment that we send out.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Daily benefit amount is 3000, right? OK, just.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] How much the patient has met?
[AGENT][NEUTRAL] And she has met the full amount of 3000.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] We sent 2,145 because that was the remaining of the 3000.
[CUSTOMER][NEUTRAL] one.
[CUSTOMER][NEUTRAL] OK, the 2,145, it is the patient amount, right?
[AGENT][NEUTRAL] Was the remaining benefit on the policy.
[CUSTOMER][NEUTRAL] OK. And patient, how much met?
[AGENT][NEUTRAL] 3000.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, just a minute.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. The daily benefit is 3000, right? And the patient has made the 3000, no?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] The patient has to use all 3000 for that date of service, correct.
[CUSTOMER][NEUTRAL] So the benefit has uh did not exhausted, no. So can you reprocess the claim.
[AGENT][NEUTRAL] The benefit amount is 3000. The member has used 3000, so the benefit amount has been exhausted.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes, sir. uh.
[CUSTOMER][NEGATIVE] Yeah, member has uh did not use above 3000, no.
[AGENT][NEUTRAL] He, the member use all 3000. The policy benefit is only 3000.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] The member has to use all 3000.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, just
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, OK, just be online. I'm checking here. Just a minute.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Uh, are you there?
[AGENT][NEUTRAL] Yes, I'm here.
[CUSTOMER][NEUTRAL] Yeah, what's the policy type?
[AGENT][NEUTRAL] This is a secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Secondary supplementary plan, right?
[AGENT][NEUTRAL] Secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And uh does the patient has paid any premium?
[AGENT][NEUTRAL] Premium
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, what do you mean by if he paid any premium?
[CUSTOMER][NEUTRAL] Premium amount.
[AGENT][NEUTRAL] We cannot release that information. I can only give you information about your claim.
[AGENT][NEUTRAL] You're calling about claim status, correct? And the claim status is for date of service [PII]. So I'm giving you claim status.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] We cannot release premium payments or we cannot release payment for the premium amount um that's not information that we can release.
[AGENT][NEUTRAL] Mr. [PII].
[CUSTOMER][NEUTRAL] OK. OK. OK. Can I have a call reference number?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name and today's date if you will. Do you need the spelling of my name or any other information, Mr. [PII]?
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] No, what's your name?
[AGENT][NEUTRAL] My name is [PII]. That's [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Last initial [PII].
[CUSTOMER][POSITIVE] OK, thank you for assisting me. Have a good day. Bye-bye.
[AGENT][POSITIVE] You're welcome. You as well. Thank you for calling APL. Bye-bye, Mr.