AccountId: 011433970860
ContactId: 10fff44b-9ce1-4747-8377-dfa533316543
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 648119 ms
Total Talk Time (AGENT): 241430 ms
Total Talk Time (CUSTOMER): 275571 ms
Interruptions: 3
Overall Sentiment: AGENT=1.2, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/15/10fff44b-9ce1-4747-8377-dfa533316543_20250515T15:59_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], is that [PII]?
[AGENT][POSITIVE] Oh yes, [PII]
[CUSTOMER][NEUTRAL] I got it right. Hi, [PII]. My name is [PII]. I'm calling. I'm calling, I'm calling with Methodist Richardson Medical, and this call is being monitored for quality and training purposes. I need to check on 3 claims please for the same patient.
[AGENT][POSITIVE] Yeah, thanks.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure, I could check those claims for you. Uh, [PII], can I get a good callback number from you first in case we're disconnected?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Absolutely. My direct line is [PII].
[AGENT][NEUTRAL] Thank you and then uh do you have that policy number?
[CUSTOMER][NEUTRAL] Yes, I do. It is 02143353.
[AGENT][NEUTRAL] OK, and what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] [PII], date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that and you said we have 3 claims to check for the same number?
[CUSTOMER][NEUTRAL] Yes, and they're old claims, they're from [PII].
[AGENT][NEUTRAL] OK, and I just was about to say this policy termed a while ago.
[CUSTOMER][NEUTRAL] All I really, yeah, all, all I
[CUSTOMER][NEUTRAL] Yes, yeah, all I need really is um the EOBs on all three of them faxed to me or emailed to me. That's, that's really what I need. Um, and, and just more information um let me see, [PII], let me see what the next the next note needed. Hold on, give me one moment. This one was waiting for, OK, term, so it did term.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Sure. Do you
[AGENT][POSITIVE] No worries.
[CUSTOMER][NEUTRAL] Um, it turned on [PII], correct?
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And then on the then we'll talk about the second one because that one is gonna be covered, was supposed to be covered.
[CUSTOMER][NEUTRAL] And that there, so we'll talk about the last two after we get the notes after we finish with the first one then basically.
[AGENT][NEUTRAL] Sure, OK, do you have any of the claim numbers?
[CUSTOMER][NEUTRAL] Let me see. No, ma'am, I do not.
[AGENT][NEUTRAL] OK, that's fine um what was are they all for the same date of service?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] They are OK. What was that date of service?
[CUSTOMER][NEGATIVE] No, no, no, no, they're not for the the the same data, they are not for the same date of service, sorry, I got tongue twisted there.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] No worries, no, that's OK. Sure, OK, what was that first state of service?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the bill amount was $8,676.50.
[AGENT][NEUTRAL] Got it. Alright, one moment.
[AGENT][NEUTRAL] Alright, bear with me just a moment.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] And if I could get a claim number just so I can have for my records, if you have it.
[AGENT][NEUTRAL] Oh, sure.
[CUSTOMER][NEUTRAL] I know.
[AGENT][POSITIVE] Absolutely, gotta make sure I find the right one.
[AGENT][NEGATIVE] There we are. There's not OK.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Alrighty, so for this one I do have that claim number, um, but we were unable to pay a benefit as the calendar year maximum for their outpatient, um, so of course I will lead by beginning just in case you were unaware, um, that this is a limited indemnity medical plan, um, so any their benefit they have for outpatient accident sickness treatment in an emergency room, that benefit had been met to prior to this claim.
[CUSTOMER][NEUTRAL] The patient ER.
[CUSTOMER][NEUTRAL] And the maximum had been reached already.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So it's a limited indemnity plan and it was only, it only covers outpatient and the ER max had been reached, correct? Did I didn't miss anything?
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] Uh, let's see. I'm gonna get the, let's see, I don't know if I can.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Since it's termed, I'm gonna try to find the original benefit information let's see.
[AGENT][NEUTRAL] There we are, OK, so yeah, they had a calendar year maximum of uh well, I don't know that it's going to tell me because it's termed.
[AGENT][NEUTRAL] I guess I could go back and look if you needed that information.
[CUSTOMER][NEUTRAL] No, I, I don't. No.
[AGENT][NEUTRAL] OK, OK, and then I've got that claim number whenever you're ready.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] OK, that is 30.
[AGENT][NEUTRAL] 85.
[AGENT][NEUTRAL] 611.
[CUSTOMER][NEUTRAL] 308-561-1. OK.
[AGENT][NEUTRAL] Correct and we were needing all of these claims, uh, EOBs sent to you, correct?
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] Were you needing all of the EOBs sent to you?
[CUSTOMER][NEUTRAL] Yes, yes, so you can either email them or fax them.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Uh, fax would be perfect. Um, I'm ready for that number whenever you're ready.
[CUSTOMER][NEUTRAL] I'm ready. It's [PII] and it's attention, [PII], please.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and then uh I'm gonna read that back to make sure I heard that correctly that was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Attention, [PII].
[AGENT][NEUTRAL] Yes ma'am, got it. um I will go ahead and get that sent to you. Did you need any further information for this claim?
[CUSTOMER][NEUTRAL] Um, no, just a call reference number.
[AGENT][NEUTRAL] Uh, reference number would be the same for all of the ones that we checked just so you know, uh, it would be my first name, last initial, and today's date. Uh, so my last initial is A.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so it'll be [PII] 051525?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK, perfect.
[AGENT][NEUTRAL] All right and then uh whenever you're ready I can take that next data service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. The next date of service is?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the build amount is 1,032 even.
[AGENT][NEUTRAL] I'm sorry that was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And this one is because the policy um the data service is 420 and it was termed, so I just need the, I just need the EOB for that.
[AGENT][NEUTRAL] Terms
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Sting, of course I'm sorry, what did you say that build amount was [PII]?
[CUSTOMER][NEUTRAL] 1,032.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] There we are, OK, uh, did you need this claim number as well?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK, that is 31.
[AGENT][NEUTRAL] 29249.
[CUSTOMER][NEUTRAL] 3129249
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] It's the same um K A R A A 051525, correct?
[AGENT][NEUTRAL] I know.
[AGENT][NEUTRAL] Right, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Well, you are pretty easy, huh? OK.
[AGENT][POSITIVE] All righty.
[CUSTOMER][NEUTRAL] Now, the last one.
[CUSTOMER][NEUTRAL] Let's see, the last 1, 513 515. OK, the last one is date of service [PII] with a billed amount of $2,102.
[AGENT][NEUTRAL] OK, got it. One moment.
[CUSTOMER][NEUTRAL] Even.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes, I would need the claim number as well, please.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And this one's gonna be the same thing because of the maximum ER visit, I think that's what one of the notes says.
[AGENT][NEUTRAL] Most likely, um, but I can verify that.
[CUSTOMER][NEUTRAL] It says um.
[AGENT][NEUTRAL] Go to find it. Let's see there we are.
[AGENT][NEUTRAL] Yes, this one's been all reason is the same, um, that the maximum, uh, ER visit for the calendar year had been met.
[CUSTOMER][NEUTRAL] Yes, OK. And it's only it says the note that I'm seeing from [PII], um, it says that um the red states that they had received a payment at the same time the claim came in, but this state of service was denied because this is a maximum ER visit had been met, patient only allowed to a year, 2 visits a year. Does that sound right?
[AGENT][NEUTRAL] Yes, yes.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, and then I've got that um that claim number whenever you're ready.
[CUSTOMER][POSITIVE] OK. I'm ready.
[AGENT][NEUTRAL] Alright, that is 30.
[AGENT][NEUTRAL] 91577.
[CUSTOMER][POSITIVE] 3091577. Thank you so much, [PII], for all of your help. And how long will it take for those?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] You are very welcome.
[CUSTOMER][NEUTRAL] Uh, for the fax is the EOBs to come in, how long will it take for the, the, um, EOBs to come in?
[AGENT][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] I just sent uh the first two. I'm sending the 3rd 1 right now. Um, I would say no longer than you should get it within about 10 minutes, I would say.
[CUSTOMER][POSITIVE] Perfect. Thank you so much, [PII], and you have a wonderful weekend. I mean a wonderful day. That's it. We're all set.
[AGENT][NEUTRAL] Of course, yeah, was there anything else I can help you with?
[AGENT][POSITIVE] Oh, I'm ready for that weekend.
[CUSTOMER][NEUTRAL] Oh, me too.
[AGENT][POSITIVE] All right. Well, thanks, Miss [PII]. Have a great rest of your day.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You as well. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye-bye.