AccountId: 011433970860
ContactId: e1de1fab-9e94-48d1-9f68-43b44b2e3419
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 576950 ms
Total Talk Time (AGENT): 211597 ms
Total Talk Time (CUSTOMER): 121070 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/14/e1de1fab-9e94-48d1-9f68-43b44b2e3419_20250414T19:47_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling for claim status.
[AGENT][POSITIVE] OK, I can definitely help you with the claim status and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, I have 1451419.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Number is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you want me to check on?
[CUSTOMER][NEUTRAL] Data service is gonna be [PII].
[AGENT][POSITIVE] And the total, I'm sorry.
[CUSTOMER][NEUTRAL] And the billed amount is 3.
[CUSTOMER][NEUTRAL] It's OK, it's $334.
[AGENT][NEUTRAL] 334. OK.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Yes, it's for Oakville Community Hospital.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, and the provider on the claim is [PII]. It may actually I see there was another data service filed with it, so it, it may have a different bill amount. Give me one second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, it may be, um, found on a claim for data service 13 of 24 for for $508.
[AGENT][NEUTRAL] Yup, OK.
[AGENT][NEUTRAL] 839, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, so I'm sure we received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 351.
[AGENT][NEUTRAL] 4354.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim to the provider $74.02.
[AGENT][NEUTRAL] For code 99232.
[AGENT][NEUTRAL] Code 99239, which was the 334 charge was denied, uh, because the maximum benefit payable for laboratory and diagnostic testings have been met for the calendar year.
[CUSTOMER][NEUTRAL] OK, was there, um, so did it process like the patient responsibility or?
[AGENT][NEUTRAL] So we don't determine patient um responsibility because we're not the, we're the secondary insurance. So that would be um between primary or you as the provider um to determine billing or write-off for the options.
[CUSTOMER][NEUTRAL] Was it um
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, because I know most insurances process like with the, you know, it says like PR or CO like a contractual obligation that we adjust off, so.
[AGENT][NEUTRAL] Right, major medical, but for us we're the 2nd, so that's why it's not on the explanation of benefits either.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, and I do have a another claim for this member to check on.
[AGENT][NEUTRAL] Sure, what's the um data service for you?
[CUSTOMER][NEUTRAL] It is for um 818 of 24.
[AGENT][NEUTRAL] OK, and that total bills?
[CUSTOMER][NEUTRAL] It is 4, give me one second, it's got 2 charges on it.
[AGENT][POSITIVE] Take your time.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, for $286.
[AGENT][NEUTRAL] 286.
[AGENT][NEUTRAL] And the 286 is the total?
[CUSTOMER][NEUTRAL] Yeah, and that's if it processed with both charges. If not, it may just be for $31.
[AGENT][NEUTRAL] OK, here goes one for 31. OK, let me see if that's it. Hold on one second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And would it be the same provider or a different provider?
[CUSTOMER][NEUTRAL] Um, this is gonna be for provider Caleb [PII].
[AGENT][NEUTRAL] But still Oakdale
[CUSTOMER][NEUTRAL] Oh, yes, still for Oakdale.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So I'm showing we received this claim 3060. Hold on one second.
[AGENT][NEUTRAL] We received this claim on [PII].
[AGENT][NEUTRAL] That claim number is 351-4306.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim to the provider. Uh, let's see what the total is.
[AGENT][NEUTRAL] Well, hold on.
[AGENT][NEUTRAL] This claim paid out, let me see how this shows. Hold on one second because I do see the two lines here, 286. OK.
[AGENT][NEUTRAL] For some reason on the main screen, it only showed 31, but then when I clicked it, I see now I see both here, so.
[AGENT][NEUTRAL] Let me see how this was broken down. Hold on one moment.
[AGENT][NEUTRAL] OK
[AGENT][NEGATIVE] So for the $31 charge for code 71046, that claim, that um code was denied.
[AGENT][NEUTRAL] Because the outpatient benefit for the calendar year has been met.
[AGENT][NEUTRAL] And then for the 71275, there was a payment of 53 cents to that?
[CUSTOMER][NEUTRAL] OK. Yes, and I did see the payment of the 53 cents.
[AGENT][NEUTRAL] All right, [PII], was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Um, yes, ma'am. I did actually have one more claim for this member.
[AGENT][NEUTRAL] OK, and what's the date of service?
[CUSTOMER][NEUTRAL] Um, it is also for [PII].
[CUSTOMER][NEUTRAL] And it is for $24.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] You said $24?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] Here we go.
[AGENT][NEUTRAL] So I'm just waiting for the denial reason to pop up here hold on one moment.
[AGENT][NEUTRAL] 43.
[AGENT][NEUTRAL] Alright, so for this time we received it on [PII].
[AGENT][NEUTRAL] This claim number is 3514364.
[AGENT][NEUTRAL] And on [PII], the claim was denied because the outpatient benefit for the calendar year has been met.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're very welcome, [PII]. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No, that was it.
[AGENT][POSITIVE] Alrighty, well, thank you so much for calling APL. I hope you have a great day.
[CUSTOMER][POSITIVE] Thank you you too.
[AGENT][POSITIVE] You're welcome. Bye-bye.
[CUSTOMER][NEUTRAL] Alright bye.