AccountId: 011433970860
ContactId: d9e9d127-311e-45ee-b677-f3a6a06c709b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 576390 ms
Total Talk Time (AGENT): 156444 ms
Total Talk Time (CUSTOMER): 194171 ms
Interruptions: 2
Overall Sentiment: AGENT=0, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/09/d9e9d127-311e-45ee-b677-f3a6a06c709b_20250609T17:01_UTC.wav
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[AGENT][NEUTRAL] And thank you for calling and APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hello, my name is [PII] calling from provider's office to check on a claim status. Could you please spell out your name for me?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] Thank you so much. May I know your last initial?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Do you have a phone number I can get in case we get disconnected I can call you back.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yes, the callback number is [PII].
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Can you hear me?
[AGENT][NEUTRAL] Yes, I can hear you.
[CUSTOMER][NEUTRAL] Yes, the callback number is [PII] with the extension of [PII].
[AGENT][NEUTRAL] Thank you, [PII]. And do you have a policy number?
[CUSTOMER][NEUTRAL] Yes, I do have 01306681 M as in Mike, L as in Lima, number 8.
[AGENT][NEUTRAL] Thank you, [PII]. Hold on one moment, please.
[AGENT][NEUTRAL] And what's the patient's name?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Uh first name is, uh first name of the patient is [PII] and the last name is [PII] sorry, [PII]
[AGENT][NEUTRAL] And can I verify her date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, [PII], and you were just needing claim status?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, I can help you with that. What date of service?
[CUSTOMER][NEUTRAL] The date of service is [PII].
[CUSTOMER][NEUTRAL] And the total charge amount is $431 even.
[AGENT][NEUTRAL] Thank you, [PII]. Hold on one moment, please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is one of the procedure codes? Is it a facility bill or a doctor's charge?
[CUSTOMER][NEUTRAL] Sorry, could you please repeat? Your voice is uh breaking.
[AGENT][NEUTRAL] Is it for a facility bill or is it for a doctor's charge?
[CUSTOMER][POSITIVE] Facilities
[AGENT][NEUTRAL] OK, and what's that um procedure code?
[CUSTOMER][NEUTRAL] The procedure code is 73221.
[AGENT][NEUTRAL] OK, so it's for a doctor's charge.
[AGENT][NEUTRAL] We did get that claim in.
[AGENT][NEGATIVE] And it was denied.
[AGENT][NEUTRAL] They had met their outpatient.
[CUSTOMER][NEUTRAL] May I know the claim receiving from the place?
[AGENT][NEUTRAL] Can I give you the reason?
[CUSTOMER][NEUTRAL] Uh, sure. Uh denied reason, right, you are giving?
[AGENT][NEUTRAL] Yes.
[AGENT][NEGATIVE] It was denied for they had met their outpatient maximum.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] And it was received 11025.
[AGENT][NEUTRAL] And it was processed 11025.
[CUSTOMER][NEUTRAL] Processing.
[AGENT][NEUTRAL] Ma'am.
[CUSTOMER][NEUTRAL] 1 10:25.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Claim number?
[AGENT][NEUTRAL] 355-0515
[CUSTOMER][NEUTRAL] OK. As you said, the claim was uh
[CUSTOMER][NEUTRAL] Denied due to the maximum benefits is exhausted, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, could you please help me with that? Uh, may I know, uh, I mean, how many visits are there?
[AGENT][NEUTRAL] It's not a certain number of visits. They, any benefits given over the phone is not a guarantee of payment for outpatient. They get $2500 per calendar year.
[CUSTOMER][NEUTRAL] Outpatient benefits is been exhausted.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] So, could you please help me with this? I mean, uh, the denial is uh related to patient or is it is related to provider?
[AGENT][NEUTRAL] The patient's policy [PII].
[AGENT][NEUTRAL] Per calendar year.
[CUSTOMER][NEUTRAL] Oh, could you please confirm that, uh, the rendering provided is [PII], is that correct?
[AGENT][NEUTRAL] The provider for that claim.
[CUSTOMER][NEUTRAL] Yes, uh, the rendering provider is [PII]. Is, is that correct?
[AGENT][NEUTRAL] Hold on one moment and I can tell you.
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] OK. And the NPA is 1255593885, right?
[AGENT][NEUTRAL] I didn't understand your question.
[CUSTOMER][NEUTRAL] Yeah, I'm asking about rendering provider NPI I mean individual and NPA.
[AGENT][NEUTRAL] What's the NPI again?
[CUSTOMER][NEUTRAL] 1255593885
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK. So, could you please help me with that? I mean, uh, what action can we take to process this claim?
[AGENT][NEUTRAL] You can send in an appeal, but it's, it's gonna be the same because they met their outpatient max there's nothing we can pay when they met their maximum.
[CUSTOMER][NEUTRAL] outpatient benefits maximum is exhausted. So, so in this case, uh, can we
[AGENT][NEUTRAL] Right, they have met.
[CUSTOMER][NEUTRAL] In this case, can we submit a corrected claim? Is there any possibility to
[AGENT][NEGATIVE] It's still gonna be denied. It's still gonna be denied for the same thing because they have no more benefits left.
[CUSTOMER][NEUTRAL] What the corrected claim.
[CUSTOMER][NEUTRAL] Uh, may I know the correct claim timely filing if you don't mind?
[AGENT][NEUTRAL] Well you
[AGENT][NEGATIVE] We do not have timely filing.
[CUSTOMER][NEUTRAL] For the correct claim, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Uh, may I know the mailing address?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, thank you. Uh, may I know the appeal timely filing limit?
[AGENT][NEGATIVE] We do not have timely filing.
[CUSTOMER][NEUTRAL] For appeal also.
[AGENT][NEUTRAL] Right, for anything.
[CUSTOMER][NEUTRAL] And uh.
[CUSTOMER][POSITIVE] Yeah, thank you. Thank you for your assistance. Could you please help me with the call reference number?
[AGENT][NEUTRAL] We do not have call reference numbers. You can use my name in today's date.
[CUSTOMER][NEUTRAL] OK. Your name?
[CUSTOMER][POSITIVE] And today's date is [PII]. Thank you so much.
[AGENT][NEUTRAL] M
[AGENT][POSITIVE] Thank you, [PII].
[CUSTOMER][NEUTRAL] Yup, I got the required information from you.
[AGENT][POSITIVE] Thank you, [PII], for calling APL. You have a good day.
[CUSTOMER][POSITIVE] Have a nice, uh.
[CUSTOMER][NEGATIVE] My wife for no.