AccountId: 011433970860
ContactId: fcb77e90-0573-475d-958f-c2ce3e4f9947
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 447350 ms
Total Talk Time (AGENT): 127727 ms
Total Talk Time (CUSTOMER): 92058 ms
Interruptions: 1
Overall Sentiment: AGENT=1.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/28/fcb77e90-0573-475d-958f-c2ce3e4f9947_20250528T17:31_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling you from provider's office to checking on our claim status. How are you doing today?
[AGENT][POSITIVE] I'm great thanks for asking [PII]. I can assist you with that. Can I have a callback number for you?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]. Can you please spell your name for for document purpose?
[AGENT][NEUTRAL] Did you say [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] Your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] I can barely hear you. What did you say, [PII]?
[CUSTOMER][NEUTRAL] What's the last name initial?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thank you [PII].
[AGENT][NEUTRAL] And [PII], can I, you said you were calling to check the status of a claim. What is that member's policy number?
[CUSTOMER][NEUTRAL] Uh it's medical.
[AGENT][NEUTRAL] The policy number?
[CUSTOMER][NEUTRAL] Yeah, it's 016.
[CUSTOMER][NEUTRAL] 65,400.
[AGENT][NEUTRAL] And you can check the status of a claim, correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Could you verify that patient's name and date of birth?
[AGENT][POSITIVE] And I'll be able to assist you.
[CUSTOMER][NEUTRAL] The first name is [PII] Last name is [PII]
[AGENT][NEUTRAL] And what is the member's date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And what is the date of service that you're calling to check the status of a claim for Gladys?
[CUSTOMER][NEUTRAL] [PII] with the total charge of $1,525 even.
[AGENT][NEUTRAL] Could you provide me with a procedure code?
[CUSTOMER][NEUTRAL] Yeah, it is 99285 and 99,010.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] 19.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It looked like this claim was received [PII]. It was processed [PII].
[AGENT][NEUTRAL] And there was no payment made on this claim and the reason why is because the benefits were maxed out.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You said Benefit max, right?
[AGENT][POSITIVE] Yes, that is correct.
[AGENT][NEUTRAL] The benefits maxed out per the calendar year.
[CUSTOMER][NEUTRAL] Give me 1 2nd.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Uh, may I know it is
[CUSTOMER][NEUTRAL] What number of is it?
[AGENT][NEUTRAL] No, the member's benefits were maxed out for the calendar year when your claim was received.
[CUSTOMER][NEUTRAL] Give me 1 2nd.
[CUSTOMER][NEUTRAL] Is this based on uh monthly or yearly basis?
[AGENT][NEUTRAL] Yearly.
[CUSTOMER][NEUTRAL] Yearly.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] May I know the effective and termination date?
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] Policy was effective.
[AGENT][NEUTRAL] [PII] and it turned [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] OK, just a moment.
[CUSTOMER][NEUTRAL] Actually I do see our data services 529-2024.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] So can I take it back for res?
[AGENT][NEUTRAL] No, what I'm no, I'm not saying that the policy was not active at the time of the services. I'm stating that the policy benefits were maxed out for the calendar year, the insured benefits have been maxed out.
[AGENT][NEUTRAL] Before your claim was received.
[AGENT][NEUTRAL] With prior claims.
[CUSTOMER][NEUTRAL] No, actually you said that the beneficial was active from [PII], right? And the data service is coming under file just a moment.
[CUSTOMER][NEUTRAL] It's like 2 in [PII].
[AGENT][NEGATIVE] I didn't say that the policy was terminated the date of service, I stated that the policy benefits were maxed out. There were no benefits available because they were maxed out.
[CUSTOMER][NEUTRAL] Yeah, you said that benefits were maxed out and the effective date is [PII].
[AGENT][NEUTRAL] Right, and there's a
[AGENT][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] Your claim was denied because the benefits were maxed out. The member has a maximum benefit amount allowed per calendar year and they were maxed out by the time your claim was received, not that the claim, the policy was terminated, but the benefits were maxed out the date of service that you're inquiring about.
[AGENT][NEGATIVE] Therefore, no benefits are allowed because there are no benefits available.
[CUSTOMER][NEUTRAL] OK, what is the dollar amount?