AccountId: 011433970860
ContactId: e92b5e82-f952-4f1f-aba3-7d2f23d1bc9c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 534239 ms
Total Talk Time (AGENT): 148114 ms
Total Talk Time (CUSTOMER): 136890 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/e92b5e82-f952-4f1f-aba3-7d2f23d1bc9c_20250121T13:59_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, good morning. Myself, [PII], and I'm calling you from a provider's office to check a claim status.
[AGENT][POSITIVE] OK, I'll be more than happy to help you with the claim status and from my notes, can you spell your first name for me, please?
[CUSTOMER][NEUTRAL] Uh, sure. [PII]. Also, I would like to, uh, your name. How do you spell it?
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure. And uh before providing you that, I would like to let you know that all calls are being monitored for quality and training purpose and uh the callback number is [PII].
[AGENT][NEUTRAL] Thank you for that. May I have the member's policy number?
[CUSTOMER][NEUTRAL] Uh, it is 01659579 Mike Lima Bravo.
[AGENT][POSITIVE] Thank you for that. Hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII] is the name. [PII] is the date of birth.
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. May I have the date of service for the claim you'd like me to check on?
[CUSTOMER][NEUTRAL] Yeah, it is [PII] and uh the bill amount is $497.26.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold while I search for the claim?
[CUSTOMER][POSITIVE] Sure, take your time.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Something's in my eye. OK, so 44.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. So, there is a claim here, um, actually, first let me ask you, what's the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Vital empty group holding LLC.
[AGENT][NEUTRAL] OK, so there's a claim here that is um in the total of $497.26. Um, is that the claim that you're looking for?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yes, that's the better one that I told you in the beginning of the call.
[AGENT][NEUTRAL] OK, you said $497. Does the 26 cents make a difference?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Because I can give you this claim status if not.
[CUSTOMER][NEUTRAL] No, that's the amount that I'm talking about $497.26.
[AGENT][NEUTRAL] OK, hold on.
[CUSTOMER][NEUTRAL] I'm not sure whether I told you the 26 cents or not, but this is the actual bill amount.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So I'm showing that we received the claim on [PII].
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] The claim number is 352.
[AGENT][NEUTRAL] 4844.
[AGENT][NEUTRAL] And on [PII], the claim was denied?
[AGENT][NEUTRAL] And let me get that denial reason for you. Hold on one moment.
[AGENT][NEUTRAL] The claim was denied because the outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] Uh, so the claim has been denied as maximum benefit, right?
[AGENT][POSITIVE] Yes, maximum benefit has been met.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] May I know in what terms the benefit has been matched in terms of dollar value, in terms of visit?
[AGENT][NEUTRAL] In terms of dollar value, the calendar year max is $7900 per calendar year. By the time your claim was received, that balance had been used.
[CUSTOMER][NEUTRAL] Uh, you said $7000 900.
[AGENT][NEUTRAL] $7900.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] So this amount has been already met uh before our doors before [PII], right?
[AGENT][NEUTRAL] Before your claim.
[AGENT][NEUTRAL] Before your claim was received to be processed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, also, may I know, uh,
[CUSTOMER][NEUTRAL] The claim details that where the benefits has been actually matched.
[AGENT][NEUTRAL] Um, if it belongs to your provider, I can.
[CUSTOMER][NEUTRAL] Uh, can you provide me a claim number?
[AGENT][NEUTRAL] If it belongs to your provider, I can. If not, I won't be able to give that information. Hold on one moment, let me see.
[CUSTOMER][NEUTRAL] Uh, all right. Kindly check it.
[AGENT][NEUTRAL] So, no, this is a different provider.
[CUSTOMER][NEUTRAL] So under a different provider, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So, it's fine if you cannot provide me uh the claim number. However, you can definitely tell me the name of the provider, right?
[AGENT][NEUTRAL] No, I cannot give you any of the provider's claim information.
[AGENT][NEUTRAL] Because it does not belong to your provider.
[CUSTOMER][NEUTRAL] OK, all right. Uh, so I would like to have a call reference number.
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name in today's date, which is [PII]
[AGENT][NEUTRAL] The first initial to my last name is [PII].
[CUSTOMER][POSITIVE] All right, then. Uh, thank you so much. You have a great help and I hope that you have a good rest of the day.
[AGENT][POSITIVE] Alright, you're welcome and thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Yeah.