AccountId: 011433970860
ContactId: f87e9d02-18ec-4f5b-a3bd-a7d4f8a0cb48
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 412220 ms
Total Talk Time (AGENT): 148415 ms
Total Talk Time (CUSTOMER): 101684 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/f87e9d02-18ec-4f5b-a3bd-a7d4f8a0cb48_20250513T13:16_UTC.wav
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[AGENT][POSITIVE] Good Morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII] and I'm calling from provider office to check the additional information on the denied claim.
[AGENT][NEUTRAL] OK, you're needing additional information on the denial of a claim, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, I can help you with that. And can you spell your name for me, please?
[CUSTOMER][NEUTRAL] Sure. My name is [PII]. It's spelled as [PII]. My last digit would be [PII]. And as well as, can I get your last name, sir?
[AGENT][NEUTRAL] My last name initial is [PII].
[AGENT][NEUTRAL] And [PII], what is your callback number, please? You're welcome.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the member's policy number, please.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the member policy number is gonna be 02578805.
[AGENT][POSITIVE] OK, thank you one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And any information so let me that I provide for you today will be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth, please?
[CUSTOMER][NEUTRAL] Patient name is gonna be [PII] and the date of birth [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm. Welcome.
[AGENT][NEUTRAL] Data service and total bill amount.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Pardon?
[AGENT][NEUTRAL] What is the date of service and total bill amount?
[CUSTOMER][NEUTRAL] The date of service is gonna be $127 2025 with the bill on $267. 25 cents.
[AGENT][POSITIVE] Thank you and the claim number.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes ma'am, what is your claim number that you're calling about?
[CUSTOMER][NEUTRAL] Sure, I can provide you one moment. Let see the claim number is gonna be?
[CUSTOMER][NEUTRAL] 3,569,960.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Yes, ma'am. I do show that this claim was denied. The reason for the denial on here states outpatient benefit for this calendar year has been met.
[CUSTOMER][NEUTRAL] Yes, but the previously the claim has been sent back for reprocess.
[AGENT][NEUTRAL] This claim has been reviewed and it was denied as outpatient benefit for this calendar year has been met.
[CUSTOMER][NEUTRAL] Yes, uh, my question is that, um, [PII], uh, rep [PII] has been took the claim back for reprocess previously.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] Uh, let me look into that because I don't see where that was done.
[AGENT][NEUTRAL] Just one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, no, ma'am, I mean, there was a claim. I'm not sure why was it being sent back allegedly for reprocessing?
[CUSTOMER][NEUTRAL] Yes. OK, uh.
[AGENT][NEUTRAL] There was a claim that was received and processed, yes, ma'am. There was another claim that had been received and processed prior to your claim being received that maxed out the calendar year benefit.
[CUSTOMER][NEUTRAL] Uh, can I know when was the previous
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And can I know how many units have been allowed and when was the previously the claim got paid?
[AGENT][NEUTRAL] As I stated, it was a claim was paid for the same date of service that was received prior to your claim being received.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And that's all of the information that I can provide for you on that claim. Outpatient benefit maximum per calendar year for covered outpatient services is $4000.
[CUSTOMER][NEUTRAL] Is it the same provider?
[AGENT][NEGATIVE] No, ma'am, it is not.
[CUSTOMER][NEUTRAL] Pardon?
[AGENT][NEGATIVE] No, it is not.
[CUSTOMER][NEUTRAL] So can you take the claim back for review?
[AGENT][NEUTRAL] No, ma'am, you can send an appeal if you were wanting an appeal done on it, you must do that within 180 days for the date from the date of the decision.
[CUSTOMER][POSITIVE] OK, thank you so much. And can I get the call call reference number for this conversation?
[AGENT][NEUTRAL] You would use my name.
[CUSTOMER][NEUTRAL] And before that, what is the, how many minutes has been a lot?
[AGENT][NEUTRAL] Again, this is not a it's not a number of visits. I gave you the dollar amount.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Or else, how many units?
[CUSTOMER][NEGATIVE] Because it has been denied for the maximum benefits exhausted.
[AGENT][NEUTRAL] Again, there's no units I gave you, no, ma'am. This is a supplemental policy. The maximum benefit per calendar year for covered outpatient services is $4000.
[AGENT][NEUTRAL] And if you need a copy of the explanation of benefits with the remark that I read to you on there, you may print that by using that claim number and from our portal it's secured.m.
[CUSTOMER][NEUTRAL] OK.