AccountId: 011433970860
ContactId: e2e62586-446e-4a5f-9ddd-3cfefa13339a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 600159 ms
Total Talk Time (AGENT): 214041 ms
Total Talk Time (CUSTOMER): 138931 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/12/e2e62586-446e-4a5f-9ddd-3cfefa13339a_20250312T16:27_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling from provider's office to check on a claim.
[AGENT][NEUTRAL] OK, well, 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, [PII].
[AGENT][NEUTRAL] Thank you for that. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] One
[AGENT][NEUTRAL] All right. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] 02458625
[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] Yeah. My first name is spelled as [PII].
[CUSTOMER][NEUTRAL] And date of birth is [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 and the total bills for the claim you like me to check on?
[CUSTOMER][NEUTRAL] Yeah, it's uh 72-2024, up to [PII]. And the total bill amount is $1,122 even.
[AGENT][NEUTRAL] OK, so you said [PII] and then you said [PII]. So is it July or February?
[CUSTOMER][NEUTRAL] It's July, it's from [PII].
[AGENT][NEUTRAL] OK, so [PII]. OK, hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And what is the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Johns Hopkins All Children's Hospital.
[AGENT][NEUTRAL] So we have a claim on file from for [PII] with this total bill, but not [PII]. Do you still want the claim status?
[CUSTOMER][NEUTRAL] You stating there is no claim on, on file for the date of service, right?
[AGENT][NEUTRAL] I'm stating there's no claim on file that gives the date range of [PII]. We have [PII] with the same total bill of $1,122 but there's nothing from the [PII].
[CUSTOMER][NEUTRAL] OK. Initially, we have called on [PII]. Uh, well, they stated like claim is denied for maximum benefit exhausted as per plan. I do have the claim number also.
[AGENT][NEUTRAL] Is it claim number 3555763?
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] What I'm explaining to you is the date of service that you gave for [PII] is not the date of service on this claim.
[AGENT][NEUTRAL] The date of service on this claim is [PII].
[AGENT][NEUTRAL] So I was asking if you wanted this claim status. So this is the claim that you're looking for, even though it has a different date.
[AGENT][NEUTRAL] Is that correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so yes, this is, if this is the correct claim uh dates, then yes, it was denied because the calendar year maximum has been um used.
[CUSTOMER][NEUTRAL] OK. Uh, allow me a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you please, may I get the date of denial?
[AGENT][NEUTRAL] Sure, hold on one moment.
[AGENT][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] And uh can you please tell me whether it is for dollar value or visits?
[AGENT][NEUTRAL] Um, it's for a dollar value, the calendar year max has been used.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Can you please tell me how much dollar amount was allowed?
[AGENT][NEUTRAL] Sure, hold on one moment.
[CUSTOMER][NEUTRAL] Sure
[AGENT][NEUTRAL] What benefit was used? Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And is it alright if I place you on a brief hold?
[CUSTOMER][POSITIVE] Sure, not a problem.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Is that what that says?
[AGENT][NEUTRAL] OK, wait, let me make sure because she's definitely gonna ask and I want to be prepared.
[AGENT][NEUTRAL] Please be in here.
[AGENT][NEUTRAL] That's what they say.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for the wait. So the physical therapy benefit on the policy, um, it would pay up to $15.15 dollars per day with a max of 1 day per calendar year.
[CUSTOMER][NEUTRAL] OK, uh.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] How much, can you please tell me amount has patient made excluding this claim?
[AGENT][NEUTRAL] One, so it only pays one per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So did the patient
[AGENT][NEUTRAL] So this claim was yours.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Yes, may I continue or you, you're gonna go ahead?
[CUSTOMER][NEUTRAL] Hello, can you hear me?
[AGENT][NEUTRAL] Hello.
[AGENT][NEUTRAL] Yes, I can hear you. Can you hear me?
[CUSTOMER][NEUTRAL] Yes, I can hear you now.
[AGENT][NEUTRAL] OK, so the claim that it was paid on was also your claim. Um, it's from [PII]. It's claim number 3,482,870 $15 was applied to that claim, so that's one, that's the one claim for this calendar year of [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, uh, has the, has the patient made the allowed amount excluding the
[AGENT][NEUTRAL] Excluding the claim that you're calling in reference to, yes, the claim I just gave was the claim that it matched the benefit.
[CUSTOMER][NEUTRAL] OK. Excluding this claim also, patient made the dollar amount, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK. Can you please spell your name for me?
[AGENT][NEUTRAL] Sure, my name is [PII] The [PII] my last name is [PII].
[CUSTOMER][NEUTRAL] OK. Uh, so the claim number is correct, right? Uh, can you also, uh, send us the copy of the explanation of benefit?
[AGENT][NEUTRAL] Sure, what's a good fax number for you?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And should that be attention, [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And it was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Alright, so I'll go ahead and send the explanation of benefits over to you now. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No, thank you. Also, can you please provide me the call reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name and today's date.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, sure, and um.
[CUSTOMER][POSITIVE] Thank you. Thank you for assisting me. Have a great day.
[AGENT][POSITIVE] You also and thanks for calling APL. Bye-bye.