AccountId: 011433970860
ContactId: 23c7d4ea-5674-433b-a4a7-5befaaca3f94
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 441970 ms
Total Talk Time (AGENT): 141732 ms
Total Talk Time (CUSTOMER): 136859 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/04/23c7d4ea-5674-433b-a4a7-5befaaca3f94_20250404T19:52_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII], and I am calling in regards to a claim.
[AGENT][NEUTRAL] OK, Ms. [PII], I can help you with the claim. Can I please get your call back number just in case the call is disconnected?
[CUSTOMER][NEUTRAL] Yes, it's gonna be [PII].
[AGENT][NEUTRAL] Thank you ma'am and then what is the patient's name, date of birth and policy number?
[CUSTOMER][NEUTRAL] OK. Patient's name is [PII].
[CUSTOMER][NEUTRAL] [PII] Date of birth is [PII]. And did you say date of service?
[AGENT][NEUTRAL] Uh, the policy number?
[CUSTOMER][NEUTRAL] Oh, policy number, I'm sorry.
[CUSTOMER][NEUTRAL] Um, I have.
[CUSTOMER][NEUTRAL] 022 03945 ML 8
[AGENT][POSITIVE] Thank you, let me pull up that policy real quick.
[AGENT][NEUTRAL] OK, and then what is the data service in the chart out?
[CUSTOMER][NEUTRAL] OK, date service was [PII] for $6,476.
[AGENT][NEUTRAL] OK, and what were the charges after the primary paid their part?
[CUSTOMER][NEUTRAL] Um, primary didn't pay anything that was still what was left.
[AGENT][NEUTRAL] OK and then can you please.
[CUSTOMER][NEUTRAL] Primary applied to deductible. I can give you what, I can give you what they applied to the deductible.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] I'll just look up the full amount and see if I can find that, uh, and then can you also uh give me the name of the facility that you're calling from?
[CUSTOMER][NEUTRAL] Yes, Saint Augustine Endoscopy Center.
[AGENT][NEUTRAL] OK, I'm gonna put you on a brief hold while I look up this claim for you, Miss [PII] and I'll be right back.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Thank you, ma'am.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, so Ms. [PII] looking at data service of [PII] and the amount of $6,476 I do not find a claim on file for that amount, um.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII], yeah, because y'all paid.
[AGENT][NEUTRAL] OK. Do you?
[CUSTOMER][NEUTRAL] [PII] because y'all made payments it paid two separate um times but it paid incorrectly and we sent it back to be reviewed.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, can you give me the claim number?
[CUSTOMER][NEUTRAL] I'm looking um.
[AGENT][NEUTRAL] From where it paid.
[CUSTOMER][NEUTRAL] I'm, I'm trying to find it on the EOB, um.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Is it the reference number? I don't, oh wait, there's the claim number. I'm sorry. OK, so the first payment because it broke it into two different payments is 343-6093.
[AGENT][NEUTRAL] OK, and then what was the other one?
[CUSTOMER][NEUTRAL] 3484937.
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick uh huh.
[CUSTOMER][NEUTRAL] And that's the payment that's actually short paid.
[AGENT][NEUTRAL] OK, alright, let me look it up real quick. I'm gonna put you on a quick hold while I look these up and find out what's going on and I'll be right back with you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I've got the um claims pulled up and the amount that you were in question about was the claim number 3484937, is that correct? You said it was paid wrong?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, that is correct. Yes. So it paid 82,280. Sorry, go ahead.
[AGENT][NEUTRAL] OK, so after that.
[AGENT][NEUTRAL] Right after that 822 82 was paid it maxed out the calendar year benefit for the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So is that why it didn't pay the whole 996?
[AGENT][NEUTRAL] Right, because the benefit, that's what was left as far as the benefit, and that was all that they could use to pay it because at that point after paying that payment it maxed it out.
[CUSTOMER][NEUTRAL] OK, so does that mean patients responsible because y'all's explanation of benefits are very vague and don't say anything.
[AGENT][NEUTRAL] Right, we don't give patient responsibility um we don't give that out ever just because we let the provider determine, you know, if they wanna continue to bill or not.
[CUSTOMER][NEUTRAL] OK, OK, but so it was because Benefits Max was reached.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, can I just get a reference number for that then?
[AGENT][NEUTRAL] Yes ma'am, you can use my name [PII] and today's date.
[CUSTOMER][POSITIVE] All right, well thank you [PII]. I appreciate your help today.
[AGENT][POSITIVE] You're very welcome, Ms. [PII]. I hope you have a wonderful weekend and thank you for calling APL.
[CUSTOMER][POSITIVE] Yes ma'am you as well thank you.
[AGENT][NEUTRAL] Bye-bye, ma'am.
[CUSTOMER][NEUTRAL] Bye bye.