AccountId: 011433970860
ContactId: f18516a1-9340-4ecb-83f6-272df2b8d11a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 477809 ms
Total Talk Time (AGENT): 140393 ms
Total Talk Time (CUSTOMER): 182881 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/14/f18516a1-9340-4ecb-83f6-272df2b8d11a_20250214T20:28_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL. my name is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from product office checking on a claim status.
[AGENT][POSITIVE] I'll be happy to assist with claim status. Can you repeat your first name for me?
[CUSTOMER][NEUTRAL] Yes, my name is [PII].
[AGENT][POSITIVE] And if I can get a good callback number for you?
[CUSTOMER][NEUTRAL] Yes, my callback number is [PII].
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] Policy number is 01634855 M as in Mary, L as in Lima 8.
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] Member's name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] What is the date of service for the claim?
[CUSTOMER][NEUTRAL] D of service is [PII].
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Hi
[AGENT][NEUTRAL] And what's your tax ID?
[CUSTOMER][NEUTRAL] Tax ID is [PII].
[AGENT][NEUTRAL] Thank you for that information. I'm showing the claim was denied because the maximum outpatient benefit.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Was maxed out.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. Maximum outpatient benefit exhaust, am I right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] Uh just a moment.
[CUSTOMER][NEUTRAL] May I know the date of this claim?
[AGENT][NEUTRAL] Claim was received on.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] [PII] claim denied on [PII].
[CUSTOMER][NEUTRAL] you
[CUSTOMER][POSITIVE] good.
[CUSTOMER][NEUTRAL] Yeah, [PII] or [PII]?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, OK. [PII]. Am I right?
[AGENT][NEUTRAL] That's correct, [PII].
[CUSTOMER][POSITIVE] Yeah, OK. Thank you. Uh,
[CUSTOMER][NEUTRAL] May I know maximum benefit reached in terms of dollar or visit?
[AGENT][NEUTRAL] Um, dollar amount.
[CUSTOMER][NEUTRAL] Dollar, OK.
[CUSTOMER][NEUTRAL] How much dollar amount is allowed?
[AGENT][NEUTRAL] $2500 per calendar year.
[CUSTOMER][NEUTRAL] Sorry, $2500?
[AGENT][NEUTRAL] Per calendar year.
[CUSTOMER][NEUTRAL] Per calendar, yes.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Uh, how much dollar amount has patient met excluding this claim?
[AGENT][NEGATIVE] I don't understand.
[CUSTOMER][NEUTRAL] Oh sorry. May I know how much dollar amount has patient met excluding this claim?
[AGENT][NEUTRAL] The full $2500 was paid out before we received your claim.
[CUSTOMER][NEUTRAL] Sorry?
[CUSTOMER][NEUTRAL] Oh man
[AGENT][NEUTRAL] You wanna know how much of the benefit they had before we received your claim, correct?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, they had $2500 but we paid it out under different claims last year.
[AGENT][NEUTRAL] Before we received your claim, they had already, they maxed out their benefit in [PII].
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] Uh, upon checking our end, the member has met, uh, for the last year.
[CUSTOMER][POSITIVE] I'm all right.
[AGENT][NEGATIVE] I don't understand.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Yeah, the member has
[CUSTOMER][NEUTRAL] Reach the maximum benefit exhaust on November.
[CUSTOMER][NEUTRAL] But our date of service is [PII]. Could you please send the claim back for reprocess?
[AGENT][NEUTRAL] Sir, I don't think you quite understand what I'm saying. I'm sorry, I wasn't clear.
[AGENT][NEUTRAL] The patient has a maximum benefit of $2500 OK? That's all we will pay in one calendar year.
[CUSTOMER][NEUTRAL] Hey man.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, we didn't receive your claim until this year.
[AGENT][NEUTRAL] Patient has been having medical services done all last year and we've been paying on them. We received a claim from a different provider in November.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Wow
[AGENT][NEGATIVE] And that was a hospital claim and that maxed out their benefits from a data service in September. There's no more benefits to pay. I, I don't understand.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][POSITIVE] Yeah, OK. Now I'm clear. Thanks for the information.
[CUSTOMER][NEUTRAL] May I have the claim number?
[AGENT][NEUTRAL] Claim number is 3553351.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 355-3351. Am I right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Yeah, OK. Could you please spell out your good name, please?
[AGENT][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, OK. May I have the call reference number for this claim?
[AGENT][NEUTRAL] Reference is just my name [PII] last [PII] [PII], and the date and time of the call. Was there anything else I could assist with today?
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Yes. Just a moment. I have uh another claim for the same member.
[CUSTOMER][NEUTRAL] I don't
[AGENT][NEUTRAL] What is the date of service?
[CUSTOMER][NEUTRAL] Yeah, just a moment.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Another date of service is [PII].
[CUSTOMER][NEUTRAL] And the bill amount is $391 even.
[AGENT][NEGATIVE] I'm showing the same thing. Claim was denied because the benefits were maxed out.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Maxed out, yeah, for this also the same information, am I right? May I know the received date of this claim?
[AGENT][NEUTRAL] Hm
[AGENT][NEUTRAL] Claim was received on the [PII], denied on the [PII].
[CUSTOMER][NEUTRAL] Uh, [PII]. Am I right?
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] [PII] claim denied on [PII].
[CUSTOMER][NEUTRAL] Yeah, OK. May I have the claim number?
[AGENT][NEUTRAL] 3552704.
[CUSTOMER][NEUTRAL] You OK?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Thank you for your patience and assistance, [PII].
[AGENT][POSITIVE] OK, was there anything else I can assist with? Well, thank you for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Have a nice day.
[CUSTOMER][POSITIVE] You too. Have a great day.
[AGENT][NEUTRAL] Bye bye.