AccountId: 011433970860
ContactId: f9fe5427-6543-4300-ba30-d90dfe4bee0a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 630869 ms
Total Talk Time (AGENT): 225924 ms
Total Talk Time (CUSTOMER): 124117 ms
Interruptions: 1
Overall Sentiment: AGENT=1.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/f9fe5427-6543-4300-ba30-d90dfe4bee0a_20250123T20:16_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, [PII]. I'm [PII] calling from the product office.
[AGENT][NEUTRAL] Hi [PII], how can I help you?
[CUSTOMER][NEUTRAL] I'm looking for clients today.
[CUSTOMER][NEUTRAL] I'm looking for a claim today.
[AGENT][POSITIVE] OK, I'd love to help you with claim status, and do you mind if I get a quick call back number from you?
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[AGENT][POSITIVE] Thank you. And the policy number today?
[CUSTOMER][NEUTRAL] OK. The policy number is 02449815.
[AGENT][NEUTRAL] All right, and.
[AGENT][NEUTRAL] Thank you for your patience. I got that policy pulled up. Would you be able to verify for me, please, your patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh, [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] All right perfect and do you have the claim number you wanna look at or did you want us to search with the date of service?
[CUSTOMER][NEUTRAL] Search for the data service.
[AGENT][NEUTRAL] And what's that data service [PII]?
[CUSTOMER][NEUTRAL] OK. Data service is uh December 9, 2024.
[CUSTOMER][NEUTRAL] And the bill amount is
[CUSTOMER][NEUTRAL] $140. $140.
[AGENT][POSITIVE] OK, perfect.
[AGENT][NEUTRAL] And would you be able to verify for me please the name of the facility on file?
[CUSTOMER][NEUTRAL] Pro's name is
[CUSTOMER][POSITIVE] Good Night Medical.
[AGENT][NEUTRAL] Thank you. Alright, I see your claim here. It looks like we received your claim [PII]. We processed the claim [PII], and your claim number is 354-9159.
[AGENT][NEUTRAL] It looks like that claim was denied. I showed the reason stating that the outpatient benefit for this calendar year has been met.
[CUSTOMER][NEUTRAL] OK, one moment, please.
[CUSTOMER][NEUTRAL] Benefit has been met. Is that, is that what you're saying?
[AGENT][NEUTRAL] Yes, it says the outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] One moment, please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Um, may I know what is the benefit for the quote?
[AGENT][NEUTRAL] What is the benefit?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] It was under their outpatient calendar year benefit.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] a
[CUSTOMER][NEUTRAL] OK, uh, uh, I don't understand that. Can you please just, uh, explain one second, please?
[AGENT][POSITIVE] Yes, absolutely.
[CUSTOMER][NEUTRAL] Are you saying the primer has been already paid the payment?
[AGENT][POSITIVE] I can't see anything. I'm so sorry. Ask your question again.
[CUSTOMER][NEUTRAL] Yeah, are you staying, stating that the primary has been already paid the payment, that's where the benefit has been met?
[AGENT][NEUTRAL] No, we're telling you that the outpatient calendar year benefit for this patient has been met. So they only have so much of a benefit they can use with our insurance in a calendar year, and they've exhausted it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, the outpatient calendar year benefit has been already met.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. May I know the benefits, uh, do you have the information?
[AGENT][NEUTRAL] Yes, I do. I do wanna let you know any benefit information I give you over the phone is always a verification of coverage and never a guarantee of payment, um, but this insured had a calendar year benefit of $2000 for outpatient benefits.
[CUSTOMER][NEUTRAL] How much the benefit?
[CUSTOMER][NEUTRAL] The currently benefit is $2000.
[AGENT][NEUTRAL] Yes, $2000.
[CUSTOMER][NEGATIVE] I don't think we have uh me benefits.
[AGENT][NEUTRAL] So it's not necessarily with each provider, that's how much they have at every provider they go to in a calendar year for outpatient benefits. So they could have met it at any other facility that they've gone to through the calendar year.
[CUSTOMER][NEUTRAL] It may be paid by another facility as well, right?
[AGENT][NEUTRAL] It likely, yeah, if they haven't used any of their benefits with you, then it was likely met at other facilities.
[CUSTOMER][NEUTRAL] May I know when was the benefit has been met for this patient?
[AGENT][NEUTRAL] I can't tell you that I'm so sorry. I can only give you information relevant to your particular facility.
[CUSTOMER][NEUTRAL] OK. Can I have the client number one second, please. It's 259, I'm sorry, 2549159. Am I right?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It was a 3 to start, but everything else was right, so 354-9159.
[CUSTOMER][NEUTRAL] Claim. And can I have the resident in it one second, please?
[AGENT][NEUTRAL] Yes, the received date was, um, let me go back to that screen. I don't wanna say it wrong.
[AGENT][NEUTRAL] Sorry, 2449815 um.
[AGENT][NEUTRAL] We received the claim on [PII] and the denial was on [PII].
[CUSTOMER][NEUTRAL] Thank you. Have another data service for the same patient. Shall we go to the next patient, next data of service?
[AGENT][POSITIVE] Yes, absolutely, um, let me.
[AGENT][NEUTRAL] Let me get there for you.
[AGENT][NEUTRAL] Um, and what's that next data service?
[CUSTOMER][NEUTRAL] The next data service is [PII]. I'm sorry, that's what I give you now. Just a moment, please.
[AGENT][POSITIVE] No worries.
[CUSTOMER][NEUTRAL] OK. OK, just a moment, please. I'll check.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] That's right.
[AGENT][NEUTRAL] And what was the bill amount?
[CUSTOMER][NEUTRAL] Yeah, just a second, please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. The bill amount is
[CUSTOMER][NEUTRAL] $140.
[AGENT][POSITIVE] Perfect and same facility, Goodnight Medical?
[CUSTOMER][NEUTRAL] Uh, yes, right.
[AGENT][NEUTRAL] OK, alright, it looks like we received your claim on [PII].
[AGENT][NEUTRAL] It looks like.
[AGENT][NEUTRAL] Um, the claim was processed [PII].
[AGENT][NEUTRAL] I have the claim number listed as 352-683-8.
[AGENT][NEUTRAL] And I do show that this claim um denied for the same reasons stating that outpatient benefits for this calendar year have been met.
[CUSTOMER][POSITIVE] OK, thank you so much. Can I have the call reference, please?
[AGENT][NEUTRAL] Call reference, you bet you it's gonna be my name, [PII], first initial last name, [PII], and then uh today's date.
[CUSTOMER][POSITIVE] Thank you so much, [PII]. Have a great day.
[AGENT][POSITIVE] My pleasure you too, take care, [PII].
[CUSTOMER][NEUTRAL] Yeah, you too, bye.
[AGENT][NEUTRAL] Bye-bye.