AccountId: 011433970860
ContactId: f6192ae6-3a72-4769-9451-ec9d95755bb9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 622690 ms
Total Talk Time (AGENT): 221795 ms
Total Talk Time (CUSTOMER): 163677 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/02/f6192ae6-3a72-4769-9451-ec9d95755bb9_20250102T19:26_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Got a key or what that.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. My name is [PII].
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] and I'm calling from IT.
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] and I'm calling from ISC Health Center and I'm looking for the status of a claim.
[AGENT][POSITIVE] OK, I'll be more than happy to assist you with your claim. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] 1
[AGENT][NEUTRAL] OK, and [PII], may I have a good contact number in case we're disconnected in the member's policy?
[CUSTOMER][NEUTRAL] I have only one clinic.
[AGENT][NEUTRAL] May I have your first name?
[CUSTOMER][NEUTRAL] OK, sure. It's [PII] [PII].
[CUSTOMER][NEUTRAL] Sure, [PII]. My first name is [PII] and my callback number is [PII].
[AGENT][NEUTRAL] Thank you. I think there may be a delay, so I'll pause after I finished talking, but may I have the member's policy number?
[CUSTOMER][NEUTRAL] Sure. Member's policy number is 02351710.
[AGENT][POSITIVE] Thank you for that. Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Member's first name is [PII], last name is [PII], and 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. May I have the date of service for the claim and the total bill?
[CUSTOMER][NEUTRAL] Date of service is [PII] and bill amount is $579.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[AGENT][NEUTRAL] Hello, [PII].
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Oh sorry. It's ISC Health Center.
[AGENT][POSITIVE] Thank you for that. And I'm showing that we received the claim.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] There's a delay on the call, so you may have to pause.
[AGENT][NEUTRAL] In between to hear the response.
[CUSTOMER][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] I'm showing that the claim was received on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim number is 353-63992.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] And on [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] We paid out on the claim a total of $75.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I'm
[CUSTOMER][NEUTRAL] Are we calling.
[AGENT][NEUTRAL] Did you need the checking information?
[CUSTOMER][NEUTRAL] Uh, yes, [PII]. Uh, I want to know what is the denial reason on leftover payment.
[AGENT][NEUTRAL] Um, so the, the code that we paid out on is 99204. Uh, we paid the max for that data service, which is $75. The other
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Codes, let me see what, what they were denied for.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Oh, they were denied because the maximum benefit um has been paid for the data service.
[CUSTOMER][NEUTRAL] OK. May I know in which terms the maximum benefit limit is?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Can you repeat that, please?
[CUSTOMER][NEUTRAL] Uh, may I know in which terms maximum benefit is there like, uh,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Are you asking me dollar amount or if it was the
[CUSTOMER][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] OK. It's raised in dollar amount, uh.
[AGENT][NEUTRAL] Um, hold on one moment. I'm pulling up the benefits so that I can give you the max for the benefit. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the outpatient sickness rider is up to $75 with a max of 5 visits per calendar year. So that full $75 was applied to this claim.
[CUSTOMER][NEUTRAL] So I know only 5 visits are allowed in a year.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, ma'am, there's a delay, so you may have to wait in between so you can hear the answer.
[CUSTOMER][NEUTRAL] Uh hello, [PII].
[AGENT][NEUTRAL] Yes, I'm here.
[CUSTOMER][NEUTRAL] May I know if uh patients visit exhausted for the year?
[AGENT][NEUTRAL] Um, hold on one second.
[CUSTOMER][NEUTRAL] Is patient visit exhausted for the year? OK.
[AGENT][NEUTRAL] I understand the question. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, for the year of [PII], they only use three of the five.
[CUSTOMER][NEUTRAL] And another.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Uh, yes, [PII]. Uh, so if a patient only use 3 out of 5, so it needs to be reprocessed.
[AGENT][NEUTRAL] No, it's per visit, so that was one date of service, um, [PII]. So [PII] will be another visit, but if it's all on the same day, that's one day, one visit.
[CUSTOMER][NEUTRAL] One visit allowed on one day.
[CUSTOMER][NEUTRAL] Could you please repeat that again?
[CUSTOMER][NEUTRAL] What.
[AGENT][NEUTRAL] The benefit is $75 with a max of 5 visits per calendar year. So for the date of service, [PII] that used one of the visits for the calendar year, which is why we paid the $75 which was the max for that benefit.
[CUSTOMER][NEUTRAL] I do.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. So [PII], the bill should be billed to the patient or it should be adjusted?
[AGENT][NEUTRAL] Um, we don't determine patient responsibility. If there is an outstanding balance, um, that would be for the provider to determine if it's patient responsibility, write off, and whatever your process is at that point.
[CUSTOMER][NEUTRAL] OK. So we can bill to the patient or not?
[AGENT][NEUTRAL] That's the same question. So we don't determine [PII]ient responsibility, so I cannot tell you to bill to the patient. If there's an outstanding balance, whatever your procedures are for outstanding balances, you'll have to follow that, but we don't determine patient responsibility, which is why it's not listed on the explanation of benefits.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][POSITIVE] OK. Sure, [PII]. Thank you so much. May I have the reference number, call reference number?
[AGENT][NEUTRAL] Sure, so there's no um call reference number, but you can use my name and today's date. The first initial to my last name is [PII] like [PII].
[CUSTOMER][POSITIVE] OK. Sure, [PII]. Thank you so much. Have a great day.
[AGENT][POSITIVE] You're very welcome, [PII]. Was there anything else I can help you with today?