AccountId: 011433970860
ContactId: 1fe6446c-9b2c-4b7a-a139-770c18c71d65
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 410959 ms
Total Talk Time (AGENT): 118003 ms
Total Talk Time (CUSTOMER): 196210 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/15/1fe6446c-9b2c-4b7a-a139-770c18c71d65_20250415T21:33_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi [PII], I have a question about a claim. I was gonna see if you could help me with.
[AGENT][NEUTRAL] OK, may I have your name, please?
[CUSTOMER][NEUTRAL] Yes, it's [PII]
[AGENT][NEUTRAL] And a callback number.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And are you the provider insured?
[CUSTOMER][NEUTRAL] Provider.
[AGENT][NEUTRAL] And may I please have that policy number?
[CUSTOMER][NEUTRAL] Yes, it's 1480429 ML7.
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] And thank you so much [PII] for verifying the policy. How may I assist you?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I was looking um at his claim on your portal.
[CUSTOMER][NEUTRAL] And I, I've got a question, it's.
[CUSTOMER][NEUTRAL] It's been processed.
[CUSTOMER][NEGATIVE] But I'm having difficulty.
[CUSTOMER][NEUTRAL] Understanding I guess the um EOB.
[AGENT][NEUTRAL] OK, do you have the claim number?
[CUSTOMER][NEUTRAL] it says, I mean I.
[CUSTOMER][NEUTRAL] Sure, yeah, um, claim number 356-0631.
[CUSTOMER][NEUTRAL] I should probably say I don't, I'm not having problems understanding it, but I'm pretty sure my payment poster is gonna come back to me with a question.
[AGENT][NEUTRAL] OK, I have that claim pulled up and.
[CUSTOMER][NEUTRAL] If I send it to her.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What issue are you having?
[CUSTOMER][NEUTRAL] Well, it says that um
[CUSTOMER][NEUTRAL] Inpatient benefits for this calendar year has been met so.
[CUSTOMER][NEGATIVE] Page 0, but it doesn't indicate is this patient's responsibility because their benefits have been met? Is this supposed to be some sort of straight up denial that I need to work and appeal or or what?
[AGENT][NEUTRAL] OK, so with this is stating that there's nothing else that we could pay out for this member that their maximum year has been met.
[AGENT][NEUTRAL] So if there was a responsibility on the primary insurance, we were not able to pay it on this claim.
[CUSTOMER][NEUTRAL] Hold on, I'm going back to see how much was left after primary paid. Yeah, there was a $41.92 left co-insurance after, uh, primary paid, so.
[CUSTOMER][NEUTRAL] So on this again on this remit it doesn't indicate.
[CUSTOMER][NEUTRAL] Any patient responsibility.
[CUSTOMER][NEUTRAL] So is that what you're saying?
[AGENT][NEUTRAL] We only go off of the primary insurance, so we denied the claim.
[CUSTOMER][NEUTRAL] On your end?
[AGENT][NEGATIVE] It's denied that the member had no other benefits available for us to pay. That's a denial.
[CUSTOMER][NEUTRAL] No other benefits for you to pay. Are you saying that you need the primary EOB?
[AGENT][NEUTRAL] No, ma'am, we have the primary EOB we have all the information, but the member has no benefits that we could pay out to the provider.
[AGENT][NEUTRAL] Because the member has already maxed out their benefits for this year, that year.
[CUSTOMER][NEUTRAL] I do understand that. It's just.
[CUSTOMER][NEUTRAL] I'm asking
[CUSTOMER][NEUTRAL] If you've paid out as much as the plan will allow.
[CUSTOMER][NEUTRAL] Who eats the money? Do I eat the money? Do I, I mean, it doesn't say that it's patient responsibility. I just want to make sure that if the benefits have been met, that there's not a stipulation, that therefore it would be the patient's responsibility.
[CUSTOMER][NEUTRAL] After that point.
[AGENT][NEUTRAL] Since we can't make a payment and we can't tell the provider how to bill is to providers discretion if they want to submit the.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Cost to the to the insured.
[AGENT][NEUTRAL] We've, we've did all that we can. We have to deny it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And then I was gonna ask.
[CUSTOMER][NEUTRAL] If there would possibly be a way that I could get.
[CUSTOMER][NEUTRAL] Um, a remit faxed or um maybe emailed to us.
[AGENT][NEUTRAL] OK. You don't have the EOB?
[CUSTOMER][NEUTRAL] Do you do that?
[AGENT][NEUTRAL] Are you saying that you don't have the EOB?
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEGATIVE] No, I can I can pull it up on your web portal, but I'm not able to download it.
[CUSTOMER][NEUTRAL] To get it to my payment poster?
[AGENT][NEUTRAL] OK, because we issued an EOB on this claim.
[CUSTOMER][NEUTRAL] I can view it, but I mean at that point I'm doing a screenshot.
[CUSTOMER][NEUTRAL] We don't have the EOB. I'm just asking if I might be able to get one faxed to me.
[AGENT][NEUTRAL] May I have a fax number please?
[CUSTOMER][NEUTRAL] Yes, ma'am. It's [PII].
[AGENT][NEUTRAL] And are you saying with the issue of downloading, is it, is it, are, are you saying that our website is not allowing you to download the EOB?
[CUSTOMER][NEUTRAL] I don't know if it's your website or if it might be my pro or my IT blocking the download but I can see that the claim is out there it's just I can't download it the um the EOB.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I was just making sure if I needed to reach out to our IT in regards to our portal is not allowing you so that was the reason for my question.
[CUSTOMER][NEUTRAL] Yeah, no, I think it might be a pop up blocker or something that I'm gonna have to get in touch with our IT department about. I'm, I'm not sure because I normally don't have that issue with payer sites, but for some reason it doesn't like yours.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, it's no problem. I'll go ahead and get that EOB pulled up and that is for the claim number of 356-063-1. Is there anything else that I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No, ma'am, that was all thank you so much.
[AGENT][POSITIVE] You're welcome. Thank you for calling American Public Life. Have a great day.
[CUSTOMER][NEUTRAL] You too. Goodbye.
[AGENT][POSITIVE] Thank you bye.