AccountId: 011433970860
ContactId: f893745d-8ed0-4b31-b9b1-119900b48ed5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 805500 ms
Total Talk Time (AGENT): 204970 ms
Total Talk Time (CUSTOMER): 222300 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/09/f893745d-8ed0-4b31-b9b1-119900b48ed5_20250609T15:15_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from the provider office and I need assistance on a claim information.
[AGENT][NEUTRAL] OK, sure, I can assist you with claims, Ms. [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Mhm. Sure. It's [PII]. It's a direct line.
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Sure. It's 0259.
[CUSTOMER][NEUTRAL] 8062.
[AGENT][NEUTRAL] Thank you. May I have the name of the facility you're calling from for my notes?
[CUSTOMER][NEUTRAL] It's Columbia Gastroenterology Association.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yes, I do see the patient's name. It's [PII] and the date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Uh, I do see the date of service. It's [PII], with the amount of $315.
[AGENT][NEUTRAL] $315 even.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see if I can find this claim for [PII].
[AGENT][NEUTRAL] And for future you can check claim status online through our website at [PII] and that's just optional.
[AGENT][NEUTRAL] And let me pull this be one moment.
[CUSTOMER][POSITIVE] No problem. Take your time, ma'am
[CUSTOMER][NEUTRAL] And can I get your name for documentation purpose?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Sure. My name is [PII].
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] I'm still waiting on the EOB to pull up, OK.
[AGENT][NEUTRAL] OK, so it looks like we processed the claim on [PII]. Again, that was [PII], and the claim was denied. The reason for this denial is that benefit maximum for the date of service has been met.
[CUSTOMER][NEUTRAL] OK. May I know that is there any um
[CUSTOMER][NEUTRAL] dollars it will be allowed as per the date?
[CUSTOMER][NEUTRAL] Date of birth is as of the date.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, I can check the benefit amount. One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this is not a guarantee of payment, just a verification of coverage. And this one has a daily benefit of let's see.
[AGENT][NEUTRAL] OK, $50 per person per calendar, $50 per visit, maximum of 4 visits per year.
[CUSTOMER][NEGATIVE] Uh, could you please repeat once again? Your voice was, um, hurting.
[AGENT][NEUTRAL] Sure, it's $50 per visit, maximum of 4 visits per calendar year.
[CUSTOMER][NEUTRAL] OK. And um do you see that is there any other claim was billed on the same date of service?
[AGENT][NEUTRAL] We do have another claim, but it's not for this provider, so we cannot release the information on it.
[CUSTOMER][NEUTRAL] Uh, so you are saying that as for the uh patient plan, it costs only $50 in your, any date in a single day in a, in a visit, right?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] It's gonna be a daily benefit of $50 per day, 4 days per year. Mhm.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] And uh you are saying that at the time of date of service on [PII], member visited other uh hospital, right?
[AGENT][NEGATIVE] Um, not exactly. On that date of service, we receive another claim which exhausted the benefit.
[CUSTOMER][NEUTRAL] OK, so you are saying that uh on the same date of service of [PII], there is another thing we got uh receive and processed with a different provider.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, give me a moment.
[CUSTOMER][NEUTRAL] And is it able to uh provide me just name of the provider?
[AGENT][NEUTRAL] No, we cannot release any information about that provider.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you so much for that. I got all the information and I just want to confirm if it comes under the uh member responsibility as maximum benefits met?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Um, we don't have any contractual involvement on the remaining of the claim, so it's up to the provider's discretion.
[CUSTOMER][POSITIVE] OK, fine. Thank you so much for that. I got all.
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Just allow me a moment. I'm just rechecking, and I just want to confirm the claim number. It's 3603391. Am I correct?
[AGENT][POSITIVE] That is correct, yes. Mhm.
[CUSTOMER][NEUTRAL] I just.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] And let me check whether I have any other things. And before that, can I get the call reference number?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will.
[CUSTOMER][POSITIVE] OK, fine. Thank you so much and your name.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Let me check.
[CUSTOMER][NEUTRAL] OK. I do see I have one claim. Give me a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, let me close
[CUSTOMER][NEUTRAL] And the
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] that it comes under the.
[CUSTOMER][NEUTRAL] OK. I.
[CUSTOMER][NEUTRAL] OK, thank you so much for being on hold. I'm almost done. I'm just opening the other screen.
[CUSTOMER][NEUTRAL] So I just.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK. I see the other team is also with the same number.
[AGENT][NEUTRAL] OK, with the same number. What's the date of service?
[CUSTOMER][NEUTRAL] Uh, it's [PII].
[AGENT][NEUTRAL] [PII], OK.
[CUSTOMER][NEUTRAL] And the bill amount is
[CUSTOMER][NEUTRAL] 7
[CUSTOMER][NEUTRAL] Excuse me, $749 even.
[AGENT][NEUTRAL] OK, let me pull that one.
[AGENT][NEUTRAL] OK, so this one was processed on [PII] and we send a benefit amount of 250, which is the maximum benefit for the policy.
[AGENT][NEUTRAL] For this service.
[CUSTOMER][NEUTRAL] So you are saying that this plan is also got in as maximum benefit.
[AGENT][NEUTRAL] Correct, yes, mhm, the calendar year maximum for the benefits has been exhausted with the payment, mhm.
[CUSTOMER][NEUTRAL] And I just want to know that uh is it a member having primary as United Healthcare?
[AGENT][NEUTRAL] I'm sorry, can you repeat?
[CUSTOMER][NEUTRAL] Uh, could you please, uh, provide me that according to the coordination of benefits, um,
[CUSTOMER][NEUTRAL] Can I get that what is the actual strength is primary to this number?
[AGENT][NEUTRAL] Um, I'm not sure if they have another policy. We only can see the policies they have with us. This is, um, this is a limited policy, limited policy, um, indemnity plan, so we don't know if they have any other policies out there.
[CUSTOMER][NEUTRAL] Mhm, because I received it, uh, the previous claims were recorded as maximum benefit. Uh, we submitted the claim as a secondary and it was processed as a primary by Na Healthcare, and I don't see that for this one this claim was admitted, um.
[CUSTOMER][NEUTRAL] As a primary.
[CUSTOMER][NEUTRAL] So that's why I'm just asking you. And um if you don't mind, could you please provide me that when was the last coordination of benefits updated?
[AGENT][NEUTRAL] We don't coordinate benefits because this is a limited policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And can I also get the claim number?
[AGENT][NEUTRAL] Yes, the claim number on this one is 3584927.
[CUSTOMER][POSITIVE] Thank you so much for that. I got it.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Time
[CUSTOMER][NEUTRAL] OK, fine. Thank you. I got all the information from you. I think I don't have any other.
[CUSTOMER][NEUTRAL] Let me reach you
[CUSTOMER][POSITIVE] I don't have any other games also. That's it. Uh thank you and have a great day. Bye-bye.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] You as well, Mr. [PII]. Thank you for calling EPL. Bye-bye.