AccountId: 011433970860
ContactId: 1fca3d5c-bdd3-47db-bfb2-1aa80d7c9d51
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1012059 ms
Total Talk Time (AGENT): 251083 ms
Total Talk Time (CUSTOMER): 306296 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/16/1fca3d5c-bdd3-47db-bfb2-1aa80d7c9d51_20250116T19:48_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is How may I assist you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from provider's office to check claim status.
[AGENT][NEUTRAL] OK, sure, I can assist you with claim status, Mr. [PII]. And may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yeah, sure. The callback number is [PII]. It's a direct line.
[AGENT][NEUTRAL] OK, thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Sure, it is D as in Delta 476-83810.
[AGENT][NEUTRAL] Do you see a policy certificate number? It's gonna start with a 0 followed by 7 digits. That's gonna be our number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And this is not your policy number, is that right?
[AGENT][NEUTRAL] No, the D number is not our policy number. That is only for IMA.
[CUSTOMER][NEUTRAL] So, could you please transfer the call to IMA?
[AGENT][POSITIVE] Oh, sure. Yes, I can do that.
[AGENT][NEUTRAL] Uh, one moment, let me go go ahead and transfer the call. Is there anything else I'm gonna help you with today before I transfer?
[CUSTOMER][NEUTRAL] Yeah, like, actually, um, the first call was taken by IMA and the rep stated that, uh, for the client status, uh, we have to transfer the call to APL. That's why I'm just transferring this line.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, then, uh, do you have a different policy number so I can locate the account?
[AGENT][NEGATIVE] Because that number you're giving me is not our number.
[CUSTOMER][NEUTRAL] Sorry, this is the.
[CUSTOMER][NEUTRAL] OK. This is the only number I have. So could we transfer the call to IME.
[AGENT][NEUTRAL] OK, do you have a social?
[CUSTOMER][NEUTRAL] Sorry, I didn't get that.
[AGENT][NEUTRAL] Do you have a social for this number?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] No, would you like me to do a name search?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What's the spelling of the last name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. And the spelling of the first name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you one moment.
[AGENT][NEUTRAL] Do you know her address?
[CUSTOMER][NEUTRAL] Yes. And the address is [PII].
[CUSTOMER][NEUTRAL] Leiser Bay.
[CUSTOMER][NEUTRAL] APT 103.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that's the address for Miss [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] What is her date of birth?
[CUSTOMER][NEUTRAL] Uh, date of birth is [PII].
[AGENT][NEUTRAL] It was [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. What is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] That of service is [PII].
[CUSTOMER][NEUTRAL] The amount is $607 even.
[AGENT][NEUTRAL] OK, let me see if I can find this claim, and that was [PII] 4607, correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I didn't catch your name. May I know your name, please?
[AGENT][NEUTRAL] My name is [PII]. That's [PII].
[CUSTOMER][POSITIVE] Thank you for that.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, I'm still searching, OK? One moment.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] I'm waiting on the EOB.
[CUSTOMER][NEUTRAL] Sorry, I didn't get that.
[AGENT][NEUTRAL] I'm waiting for the explanation of benefits to pull up.
[CUSTOMER][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it looks like we processed this claim on [PII].
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And we send a benefit amount of $50 to the provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. What about the remaining amount?
[AGENT][NEUTRAL] OK, the remaining amount, it looks like, um, but the check, the maximum benefit has been exhausted, so any remaining balance will be patient's responsibility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, can I get the uh claim number?
[AGENT][NEUTRAL] Yes, claim number 349-0413.
[CUSTOMER][NEUTRAL] OK like uh.
[CUSTOMER][NEUTRAL] The allowed unpaid amount is $50.
[CUSTOMER][NEUTRAL] Is that right?
[AGENT][NEUTRAL] The maximum benefit is $50.
[AGENT][NEUTRAL] This is not a major medical. This is a limited policy and this is an indemnity policy which pays an indemnity amount, which is a flat amount.
[CUSTOMER][NEUTRAL] Uh, like, uh, the member has only the limited policy, that's, that's why the maximum benefit amount is $50 is that right?
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] Like as you said, this is, uh, the remaining amount is going to be the responsibility, but we don't have the, um, member responsibility you will be, so could you please share the member responsibility you'll be through fax.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] We do not, we're not a major medical. Again, Mr. [PII], Mr. [PII], um, we do not have anything that shows that it's members responsibility because we're not a major medical. We are a hospital indemnity plan. So the denial is gonna state that the with the check, the maximum benefit for the state of service has been met. That is the denial reason for the remaining.
[CUSTOMER][NEUTRAL] Sorry, I didn't get that.
[AGENT][NEUTRAL] OK, uh, the denial reason for the remaining balance is that with the check, the maximum benefit for the date of service has been met.
[CUSTOMER][NEUTRAL] OK, like I have, uh, accepted that, um, denial reason. Uh, and you said, uh, the remaining amount is going to be the members responsibility, is that right?
[AGENT][NEUTRAL] It's up to the provider's discretion we cannot really tell you what to do with the remaining balance.
[CUSTOMER][NEUTRAL] Uh, like the total amount is going to be the providers right off?
[AGENT][NEUTRAL] It's up to the provider's discretion. We cannot tell you what to do with the remaining balance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just give me a moment to check this from our side.
[AGENT][NEUTRAL] Mhm. Sure.
[CUSTOMER][POSITIVE] OK. Thank you for being on a long hold.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Like you said, uh, the maximum benefit was this member is $50 and it was met and the remaining amount is going to be the, uh, providers responsibility or the m[PII] responsibility. So the provider can decide the
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, remaining amount decision, is that right?
[AGENT][NEUTRAL] Correct. They can decide what to do with the remaining. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you for that. And I have one more claim for a different member.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, let me go ahead and make a note on this one so we can move forward to the next 11 moment. And you don't need any other information on this one?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] No, that's all for this client.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] OK, what's the next policy number?
[CUSTOMER][NEUTRAL] And actually the next policy number is going to be the.
[CUSTOMER][NEUTRAL] Uh, it starts with the letter D as in Delta 42064192.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We can use that number. Do you have a policy number?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] No, I don't have the policy number. I have uh
[CUSTOMER][NEUTRAL] The member's name, uh, shall we move with the member's name or the social security number?
[AGENT][NEUTRAL] If you have the social security number, we can use that.
[CUSTOMER][NEUTRAL] OK. It is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] I you.
[AGENT][NEUTRAL] Let me repeat it back to you. That's [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] The name of the member is [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][NEUTRAL] OK. And what's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah, sure. The date of service is [PII].
[AGENT][NEUTRAL] OK, how may I assist you?
[CUSTOMER][NEUTRAL] And the bill amount is 7.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, the bill amount is $795 even.
[AGENT][NEUTRAL] OK. All right, let me see if I can find this claim for you. One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that was [PII].
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Like
[AGENT][NEUTRAL] We don't have a claim for [PII] for this member.
[CUSTOMER][NEUTRAL] Actually, the claim was resubmitted on [PII], so can you please check with the resubmitted date?
[AGENT][NEUTRAL] There's no claim pending, so we have not received anything.
[CUSTOMER][NEUTRAL] OK, so, um, we have sent it through electronically and paper, so we have sent it both and the payer ID is 64556.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the mailing address [PII].
[CUSTOMER][NEUTRAL] 27, 21704 Eagan, Minnesota.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm. And that is correct, but we have not received that claim.
[CUSTOMER][NEUTRAL] Is this uh.
[CUSTOMER][NEUTRAL] OK, and may I know the um family finding limit to resubmit the claim.
[AGENT][NEGATIVE] We don't have timely filing limits.
[CUSTOMER][NEUTRAL] Mhm. OK. And may I know the member effective on term date?
[AGENT][NEUTRAL] All right, um, let me get that for you.
[AGENT][NEUTRAL] OK. Effective date is uh [PII] and it is active at the moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm just looking up that is.
[CUSTOMER][POSITIVE] OK, thank you for that information and uh.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Can I get the call reference number for this? All the calls?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in the state.
[CUSTOMER][POSITIVE] OK. Thank you for that and have a great day to you.
[AGENT][POSITIVE] US so, Mr. [PII], thank you for calling APL. bye-bye.