AccountId: 011433970860
ContactId: fa3ca1ee-0410-41b1-88f6-bfe52b735938
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 279809 ms
Total Talk Time (AGENT): 115889 ms
Total Talk Time (CUSTOMER): 199259 ms
Interruptions: 15
Overall Sentiment: AGENT=1.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/fa3ca1ee-0410-41b1-88f6-bfe52b735938_20250103T17:54_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is So. How may I assist you?
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] I'm OK
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from provider service. Check the claim status.
[AGENT][NEUTRAL] OK, um, sure, I can assist you with the claim status, Miss Miss [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Contact number is [PII]. Direct line no extension.
[CUSTOMER][NEUTRAL] Patient policy number is 02512377.
[AGENT][NEUTRAL] Thank you. And what is the patient's policy number, Miss?
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] May I get your name again?
[AGENT][NEUTRAL] Sure. My name is [PII]. That's [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And may I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Patient first name is [PII]. Last name is [PII], and her date of birth is [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, perfect. And may I have um the date of service and the amount of the claims?
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Uh, data service is [PII].
[AGENT][NEUTRAL] And how much is the total charge?
[CUSTOMER][NEUTRAL] And total charge amount is 546 or even 546.
[AGENT][NEUTRAL] OK, let me see if I can find this claim for you. And for the future, you can check claim status online through our website at [PII].
[CUSTOMER][POSITIVE] I was so good.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Do you know what's the procedure code?
[CUSTOMER][NEUTRAL] All of the procedure codes got denied, ma'am like uh 96372.
[AGENT][NEUTRAL] 93672. OK. I just needed a procedure code so I can find your claim. OK, one moment.
[CUSTOMER][NEUTRAL] 99215, yeah.
[CUSTOMER][NEUTRAL] OK. 963-72.
[CUSTOMER][NEUTRAL] 99215.
[CUSTOMER][NEUTRAL] J1885.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I'm waiting on the ELB.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] OK, so it looks like we processed this claim on [PII] and the claim was denied stating that the calendar year maximum for outpatient benefits has been exhausted for the year.
[CUSTOMER][NEUTRAL] all the.
[CUSTOMER][NEUTRAL] Mmm that is a denial right for all the procedure codes maximum benefits has been exhausted.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] How many visitors, how many units allowed for this procedure code?
[AGENT][NEUTRAL] It's not per procedure. It's basically for outpatient service. Let me go ahead and check how much is the maximum for the outpatient service benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It is not a patient responsibility, right?
[AGENT][NEUTRAL] It's up to the provider's discretion. This is not a major medical. This is a limited policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] In your side it's listed as a patient responsibility?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm sorry, can you, can you repeat?
[CUSTOMER][NEUTRAL] In your side, it is listed as a patient responsibility.
[AGENT][NEUTRAL] We don't have any contractual involvement on the remaining of the claim.
[CUSTOMER][POSITIVE] OK, no issues.
[AGENT][NEUTRAL] We're not a major medical. OK. All right, so this policy has a calendar year maximum of 4 visits per person per calendar year and that's $30 per visit. So they already use all 4 visits. That's why, that's why it was denied.
[CUSTOMER][NEUTRAL] like
[CUSTOMER][NEUTRAL] May I know when the last visit was used? Do you have any, ah, OK, what about the call reference number?
[AGENT][POSITIVE] We can now really the information.
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will.
[CUSTOMER][POSITIVE] OK thank you have a great day.
[AGENT][POSITIVE] You you as well. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Uh-huh, no thanks, ma'am. That's all for today.
[AGENT][POSITIVE] OK. Thank you for calling APL. Have a good day. Bye-bye.