AccountId: 011433970860
ContactId: f086a943-8693-4929-9056-2e394ebf43fe
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 749900 ms
Total Talk Time (AGENT): 260595 ms
Total Talk Time (CUSTOMER): 263255 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/f086a943-8693-4929-9056-2e394ebf43fe_20250513T13:01_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, this is [PII] calling from our provider's office to check the claim status.
[AGENT][NEUTRAL] OK, well, I wanna have the claim status and [PII], may I have
[AGENT][NEUTRAL] case we disconnected?
[CUSTOMER][NEUTRAL] Yeah, can you please drop it louder?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] I can't hear you.
[AGENT][POSITIVE] I'll be more than happy to help you with the claim status. May I please have your phone number and the member's policy number?
[CUSTOMER][NEUTRAL] Yeah, the
[CUSTOMER][NEUTRAL] Yeah, the callback number is [PII]. It's direct line and the member.
[AGENT][NEUTRAL] I'm sorry, hold on one moment.
[AGENT][NEUTRAL] Can you give me the information slowly, please? I have to type it.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] Yeah, OK. The callback number is [PII].
[CUSTOMER][NEUTRAL] And uh it is direct line?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The member ID number is D for Delta 47007173.
[AGENT][NEUTRAL] Alright, and [PII], do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] Can you please repeat once again?
[AGENT][NEUTRAL] Do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] On the card, do you see anywhere that says in hospital or outpatient policy cert number?
[CUSTOMER][NEUTRAL] Yeah, OK, once again, can I check for that?
[CUSTOMER][NEUTRAL] Oh yeah, what do you want for in this card?
[AGENT][NEUTRAL] On the ID card, do you see anywhere that says in hospital or outpatient policy cert number? It should start with a 01 or 02.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yeah, yeah, the policy number is 02571829.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] Can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, the member's first name.
[CUSTOMER][NEUTRAL] Yeah, one second.
[CUSTOMER][NEUTRAL] Yeah, the member's first name is [PII] and the last name is [PII]. The 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 um date of service and the total bills for the claim?
[CUSTOMER][NEUTRAL] Yeah, the the data service is.
[CUSTOMER][NEUTRAL] [PII] and the total bill amount is $484.56.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] And what is the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah, the providers of.
[CUSTOMER][NEUTRAL] Yeah, that is American Family Care Atlanta, [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] So you received the claim on [PII].
[CUSTOMER][NEUTRAL] Yeah, once again.
[CUSTOMER][NEUTRAL] Can you please once again for the when the claim was received?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] The claim number is 3571519.
[CUSTOMER][NEUTRAL] Yeah, can you please repeat once again to the claim number slowly.
[AGENT][NEUTRAL] 357.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] 1519.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We paid out on the claim?
[AGENT][NEUTRAL] A total of 15
[CUSTOMER][NEUTRAL] March
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Can you please, uh, March date you say for that, which, what is the date?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yeah, OK, [PII].
[CUSTOMER][NEUTRAL] Uh, how much, uh.
[AGENT][NEUTRAL] So on that day we processed the claim and we made a payment of $50.
[CUSTOMER][NEUTRAL] Yeah, how much? $50?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, um, but, uh, I have that, uh.
[CUSTOMER][NEGATIVE] I have them here for that question, uh, the CPT code [PII] and 878804 and [PII] with the 59 modify the three codes are denied here I'm showing for that uh three codes are denied.
[CUSTOMER][NEUTRAL] So what is the reason for that denied?
[AGENT][NEUTRAL] Because the maximum benefit for that date of service has been met. So this is a hospital indemnity policy.
[AGENT][NEUTRAL] So the be, go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Yeah, yeah, can you see please see for that?
[AGENT][NEUTRAL] May I continue?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So the policy is a hospital indemnity policy?
[AGENT][NEUTRAL] The benefit is
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For the physician's office is $50 per visit with a max of 4 visits per calendar year. So the $50 was applied to code 99214. That's the max that can be applied.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, OK. Can you please repeat once again for that, the benefits?
[AGENT][NEUTRAL] The benefit is $50.
[AGENT][NEUTRAL] Per visit
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] With a max of 4 visits.
[CUSTOMER][NEUTRAL] For visit it, OK.
[AGENT][NEUTRAL] Per calendar year.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The $50 was applied to code 99214.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That is the max benefit.
[CUSTOMER][NEUTRAL] Yeah, OK, uh, now the members have been, uh, visit for that 4 visit for the provider's office in 4 times that he can visit.
[CUSTOMER][NEUTRAL] Or how many times he can visit?
[AGENT][NEUTRAL] 4 times per calendar year.
[CUSTOMER][NEUTRAL] Yeah, but, uh, this, uh, this calendar year May is the now is, uh, May, uh, that means, uh, 5 months is over.
[AGENT][NEUTRAL] Are you trying to ask me how many he's used for this year?
[CUSTOMER][NEUTRAL] Yeah, how many benefits you used for this scanner year?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] Um, so far he has only used the one, the one that was applied to this claim.
[CUSTOMER][NEUTRAL] Yeah, only he used for one.
[CUSTOMER][NEUTRAL] Uh, 11 calendar he's visit it for only one time for the office.
[AGENT][NEUTRAL] OK, so the benefit is by the day. So [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] There were multiple lines here, but the $50 was applied for that day. So he maxed out for that day. Now, if he comes back on the [PII], then another $50 can be applied, but for the date of the [PII], we applied the max for you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, OK, and
[CUSTOMER][NEUTRAL] Uh, can you please, uh, say for that, uh.
[CUSTOMER][NEUTRAL] Can you please say for that?
[CUSTOMER][NEUTRAL] Uh, effective date of the member?
[AGENT][NEUTRAL] Um, this policy, hold on one moment.
[AGENT][NEUTRAL] Which one is this 9.
[AGENT][NEUTRAL] Policy was effective from [PII].
[CUSTOMER][NEUTRAL] Yeah, OK. Can you please repeat once again, December?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The termination date is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, OK. [PII] and
[CUSTOMER][NEUTRAL] Uh, can you please, uh, say for your name?
[AGENT][NEUTRAL] My name is [PII], [PII].
[CUSTOMER][NEUTRAL] Yeah, yeah, ma'am. OK, your first name's initial is?
[AGENT][NEUTRAL] I'm sorry, you want the first initial or my name?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] My name is [PII]
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The [PII] initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And
[CUSTOMER][NEUTRAL] The main area remaining parents is has been uh responsible for patients.
[AGENT][NEUTRAL] We don't determine patient responsibility because we're not the major medical insurance company. So it will be whatever your procedures are on outstanding or remaining balances.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The remaining balances, uh, that there will be for us for that patient, you, you can say for that's not a medical insurance you told but your remaining balance will be who is the responsible.
[AGENT][NEUTRAL] Again, we do not determine patient responsibility, so I can't answer that question, but for the remaining balance, it
[AGENT][NEUTRAL] It would be up to you as a provider or if they have a primary, but we're not primary, so we don't determine patient responsibility.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] And can you give me that call reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Thank you so much, [PII] to assist me. Have a great day. Thank you so much. Bye.
[AGENT][POSITIVE] You're welcome, [PII]. Thanks for calling APL. Yes.
[CUSTOMER][NEUTRAL] Yeah, hello, [PII]. Yeah, hello, hello? Yeah, can you please say for that process date of this claim?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The claim was processed on [PII].
[CUSTOMER][POSITIVE] Yeah, yeah, OK. Thank you so much, [PII].
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Was there anything else I can assist you with today?
[CUSTOMER][POSITIVE] No, thank you so much. Have a great day. Thank you, bye.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Bye bye.