AccountId: 011433970860
ContactId: ea27c844-0a9f-41a4-882c-b8d2c8193ad2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 542700 ms
Total Talk Time (AGENT): 114389 ms
Total Talk Time (CUSTOMER): 177870 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/16/ea27c844-0a9f-41a4-882c-b8d2c8193ad2_20250616T14:29_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling from the office office to check on a claim status.
[AGENT][NEUTRAL] OK, I'm happy to check on a claim. Can I get the patient policy number?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The patient's policy number is 785124.
[AGENT][NEUTRAL] And do you have a good callback number for documentation, please?
[CUSTOMER][NEUTRAL] [PII]. And the extension is [PII].
[AGENT][NEUTRAL] What is the patient name and date of birth?
[CUSTOMER][NEUTRAL] The patient's name is
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII], and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you. And then what's the date of service?
[CUSTOMER][NEUTRAL] Uh, we are looking for the services [PII].
[CUSTOMER][NEUTRAL] Uh, the charge amount is $511 even.
[AGENT][NEUTRAL] Do you have a different amount after the primary paid?
[CUSTOMER][NEUTRAL] $5 saving.
[AGENT][NEUTRAL] I'm sorry, how much?
[CUSTOMER][NEUTRAL] $5.
[AGENT][NEUTRAL] $55.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] I don't show any claims on file for that bill amount.
[CUSTOMER][NEUTRAL] Actually, the bill amount is $511 even.
[CUSTOMER][NEUTRAL] In the, uh, the priority is paid $197.35.
[CUSTOMER][NEUTRAL] And they are.
[CUSTOMER][NEUTRAL] Yes, uh, give me a minute.
[CUSTOMER][NEUTRAL] Yeah yeah.
[CUSTOMER][NEUTRAL] The primary left the amount, the copay, co-pay amount is $80 even.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] In that, uh, we, we got a payment from your end like $25 even and the left, yeah, and the left amount is taken as maximum benefits exceeded.
[AGENT][NEUTRAL] Of 25. Mhm.
[CUSTOMER][NEUTRAL] Uh, may I know the reason why it is exceeded?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It looks like that's the maximum benefit per visit.
[CUSTOMER][NEUTRAL] For visit, it is exceeded under the visit wise?
[AGENT][NEUTRAL] I believe so. I'm double checking. One moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So the benefit max on the patient plan was $25 per visit with a maximum of 4 visits per year. So the $25 was the maximum that was going to be paid towards the um visit.
[CUSTOMER][NEUTRAL] So, only 4 visits covered per year.
[AGENT][NEUTRAL] With $25 correct.
[CUSTOMER][NEUTRAL] So it is uh the left is uh uh the patient responsibility.
[AGENT][NEUTRAL] We're not able to advise on patient responsibility, that would be up to the facility or the provider.
[CUSTOMER][NEUTRAL] OK. Can you please spell out your name?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, sir. Uh, can you please provide the call?
[AGENT][NEUTRAL] Call reference is my name with today's date. The initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK, sir, can you, can you, can you move to next time? Actually, I have 2 more claims are there. It's a different number.
[AGENT][NEUTRAL] I just need to notate this one and then we can check another. Give me one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What's the next member's ID?
[CUSTOMER][NEUTRAL] The next number ID is uh.
[CUSTOMER][NEUTRAL] 019
[CUSTOMER][NEUTRAL] 12978
[AGENT][NEUTRAL] Patient name and date of birth?
[CUSTOMER][NEUTRAL] The patient's name is [PII].
[CUSTOMER][NEUTRAL] The and the date of birth is [PII].
[AGENT][NEUTRAL] And data service?
[CUSTOMER][NEUTRAL] I'll be looking for the detail services [PII].
[CUSTOMER][NEUTRAL] And the charge amount is $358 even.
[AGENT][NEUTRAL] Did you say [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] The charge amount is $358 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] OK, this claim was received back in July on the [PII]. It was denied [PII]. Office visits are not covered under the member policy.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] So, office visits are not covered under this policy, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] But uh the primary is already paid under the same uh place of service in the office is only.
[CUSTOMER][NEUTRAL] How they can pay, uh, may I know the reason, uh, you, you do not follow the primary, uh, rules?
[AGENT][NEUTRAL] No, we do not.
[CUSTOMER][NEUTRAL] So it is not covered under the business plan?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, OK, sir. For the next, uh, account is also, uh, it is service done under offices only.
[CUSTOMER][NEUTRAL] So you're not uh covered for office visit, right.
[AGENT][NEUTRAL] Correct, does not cover the office visit.
[CUSTOMER][NEUTRAL] It is uh it is not under only uh office visits or any uh outpatient uh visits.
[AGENT][NEUTRAL] It depends on the member's plan. This particular member's plan doesn't cover the office visit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, [PII]. Thank you. Thanks for giving information. Nothing else.
[AGENT][POSITIVE] Oh. You're welcome. Have a good day.