AccountId: 011433970860
ContactId: f4216b07-1ff1-400f-940f-2b63050a3526
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 590700 ms
Total Talk Time (AGENT): 170708 ms
Total Talk Time (CUSTOMER): 187176 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/17/f4216b07-1ff1-400f-940f-2b63050a3526_20250617T17:59_UTC.wav
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[AGENT][NEUTRAL] Hello, thanks for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII]. I'm calling from provider office to check claim status.
[AGENT][NEUTRAL] Sure, [PII], I can assist you with that. Can I have a callback number for you?
[CUSTOMER][NEUTRAL] [PII]. And this is direct line.
[AGENT][NEUTRAL] Can I have the policy number of the member that you're calling to check the status of a claim for and I'll be able to assist you.
[CUSTOMER][NEUTRAL] Uh, that is 01887294, M as in Mary, L as in Lima, number 8.
[AGENT][NEUTRAL] Can you verify the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Name is uh [PII], [PII], date of birth.
[AGENT][NEUTRAL] And what is the date of service that you're calling to check the status of a claim for?
[CUSTOMER][NEUTRAL] [PII], bill amount $333.
[AGENT][NEUTRAL] Can you provide me with one of the procedure codes?
[CUSTOMER][NEUTRAL] Uh, that thing is
[CUSTOMER][NEUTRAL] We have the S9083.
[AGENT][POSITIVE] 525257 thank you.
[AGENT][NEUTRAL] This claim was received [PII]. It was processed [PII]. There was no payment made on the claim, and the reason why there was no payment is because the policy benefits were terminated.
[CUSTOMER][NEUTRAL] OK. What is the effective date of the plan?
[AGENT][NEUTRAL] The benefits were exhausted. Give me one moment.
[CUSTOMER][NEUTRAL] Uh, you mean patient is inactive for the date of service?
[AGENT][NEUTRAL] No, the benefits were exhausted. The benefits were maxed out. The member has a maximum benefit amount per calendar year and the benefits were maxed out.
[CUSTOMER][NEUTRAL] OK. So the dollar value or the number of the visit?
[AGENT][NEUTRAL] The dollar amount.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The policy became effective [PII] and is currently active.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the yearly benefit amount was $4000 so by the time your claim was submitted that $4000 were maxed out.
[CUSTOMER][NEGATIVE] OK. So for, so the whole year, $4000 is the limit of the dollar amount and the patient has exhausted all.
[AGENT][POSITIVE] Yes, that is correct.
[AGENT][NEUTRAL] Yes, for [PII].
[CUSTOMER][NEUTRAL] So ma'am, can you send you
[CUSTOMER][NEUTRAL] OK, OK. And ma'am, uh can you uh send you view of this number via fax on our fax number?
[AGENT][NEUTRAL] What is your fax number?
[CUSTOMER][NEUTRAL] That would be [PII]. Again, it's [PII]. Attention with my name, [PII].
[AGENT][NEUTRAL] Is there anything else that I can assist you with today?
[CUSTOMER][NEUTRAL] Yes, ma'am. Claim number?
[AGENT][NEUTRAL] 356-5273565257
[CUSTOMER][NEUTRAL] OK. Uh, so now, apart from this patient, I have one more patient to check the status. So please assist me with one more patient information.
[CUSTOMER][NEUTRAL] Can I give you the member ID?
[AGENT][NEUTRAL] Bear with me while I send this information that you requested for the first patient over.
[CUSTOMER][NEUTRAL] OK. And ma'am, how much time it takes to receive the AOB?
[AGENT][NEUTRAL] I'm not sure how long it'll take for you to receive it, but I, I'm sending it over now by fax.
[CUSTOMER][NEUTRAL] Bye
[AGENT][NEUTRAL] What is the next policy number?
[CUSTOMER][NEUTRAL] 02477372 M as in Mary, L as in Lima, number 7.
[AGENT][NEUTRAL] Can you verify the patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII], uh [PII].
[AGENT][NEUTRAL] What is the date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And what is the data service that you're calling about?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] [PII], build amount $236.
[AGENT][NEUTRAL] So that's [PII]?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] And what was the bill amount?
[CUSTOMER][NEUTRAL] $236.
[AGENT][NEUTRAL] Um, do you have a procedure code?
[CUSTOMER][NEUTRAL] It's 9083.
[AGENT][POSITIVE] 636 thank you.
[AGENT][NEUTRAL] 630.
[AGENT][NEGATIVE] This claim was received April [PII]. It was processed [PII]. There was no payment made on this claim, and the reason why there was no payment.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] It's because the primary insurance pay full benefit amounts.
[CUSTOMER][NEUTRAL] Primary insurance what?
[AGENT][NEUTRAL] The primary insurance paid the full amount.
[CUSTOMER][NEUTRAL] Primary insurance pay the full amount.
[CUSTOMER][NEUTRAL] But uh ma'am, as I can check the $55 is in your bucket like we have billed to you for $55.
[AGENT][NEUTRAL] Bear with me while I pull up the claim.
[AGENT][NEUTRAL] So the ELB that was sent over with the claim showed that the member's policy, the member's plan paid $152 and there was nothing went towards deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] So you said claim is denied because primary insurance paid full amount and there is nothing balance.
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEGATIVE] There is nothing balance.
[CUSTOMER][NEUTRAL] In your bucket.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK. And ma'am, if you, uh, we wanna send any appeal, so what address should I send the appeal?
[AGENT][NEUTRAL] The address to send an appeal will be the same address to send a claim. It is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK. That.
[CUSTOMER][NEUTRAL] And the claim number?
[AGENT][NEUTRAL] Bear with me.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] 25625. Claim number is 359-6306.
[CUSTOMER][NEUTRAL] And ma'am, uh please send this information to you also via fax or fax number attention with my name, [PII].
[AGENT][NEUTRAL] Is there anything else that I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] Oh yes, ma'am. Uh, claim, uh sorry, call reference number.
[AGENT][NEUTRAL] We don't provide those unfortunately, but you can feel free to use my name and today's date as a reference and could you provide me with the fax number one more time?
[CUSTOMER][NEUTRAL] OK. Uh, the fax number will be [PII]. Again, [PII]. Attention with my name, [PII]. And ma'am, your name spelling?
[AGENT][NEUTRAL] All right, and
[AGENT][NEUTRAL] [PII]. Today's date as a reference.
[CUSTOMER][POSITIVE] OK. Thank you, ma'am.
[AGENT][POSITIVE] You're welcome, thank