AccountId: 011433970860
ContactId: 279ac36d-4e75-47c4-9c14-ee8a42dfddce
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 466329 ms
Total Talk Time (AGENT): 184576 ms
Total Talk Time (CUSTOMER): 161594 ms
Interruptions: 0
Overall Sentiment: AGENT=1.2, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/22/279ac36d-4e75-47c4-9c14-ee8a42dfddce_20250122T20:12_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from provider's office. I have one question and claim.
[AGENT][POSITIVE] OK, yeah, I'd love to help you with that claim today, Ms. [PII]. And do you mind if I get a good callback number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure. It's [PII].
[AGENT][POSITIVE] Perfect. And the policy number for your claim?
[CUSTOMER][NEUTRAL] Sure. The policy number is
[CUSTOMER][NEUTRAL] 02408892.
[AGENT][NEUTRAL] All right, let me pull that up for you.
[CUSTOMER][NEUTRAL] And can I have your name, please?
[AGENT][NEUTRAL] Oh yeah, it's [PII]
[AGENT][NEUTRAL] First initial last name [PII].
[AGENT][NEUTRAL] And
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] Oh, it's my pleasure. Um, what is.
[AGENT][NEUTRAL] I'm so sorry. Can I have your insured's first and last name and date of birth, please?
[CUSTOMER][NEUTRAL] Sure. It's [PII], date of birth, [PII].
[AGENT][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And do you have the claim number you want us to look at today or do you want me to search for it?
[CUSTOMER][NEUTRAL] Um, I do have the claim.
[AGENT][POSITIVE] No worries, I can find that for you.
[CUSTOMER][NEUTRAL] And I do also
[CUSTOMER][NEUTRAL] Mm, I don't have the claim actually.
[AGENT][NEUTRAL] OK, I can search for it. What is the date of service?
[CUSTOMER][NEUTRAL] Um, the rate of service is [PII].
[AGENT][NEUTRAL] All right, and then that billed out?
[CUSTOMER][NEUTRAL] There is $33,181 even.
[AGENT][NEUTRAL] You said 33,000.
[AGENT][NEUTRAL] What?
[CUSTOMER][NEUTRAL] 1 it's $33,181 even.
[AGENT][NEUTRAL] Alright and then the amount after primary?
[CUSTOMER][NEUTRAL] I'm sorry, what's that?
[AGENT][NEUTRAL] The total charge after uh primary?
[CUSTOMER][NEUTRAL] After primary. Actually, the total charge amount is $33,181 even. That's the total charge amount.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And if you want to know the primary status, how much they have paid, is that what you want to know?
[AGENT][NEUTRAL] I just want to know the remaining balance after primary page.
[CUSTOMER][NEUTRAL] OK. There was just one.
[CUSTOMER][NEUTRAL] After the primary payment, the remaining balance was $4,814 even.
[AGENT][NEUTRAL] Perfect then it's definitely this claim and I just need you to verify for me please the name of the provider's office on file.
[CUSTOMER][NEUTRAL] That's mhm that is Chitam Surgery Center.
[AGENT][POSITIVE] Perfect. Alright, I do see that this claim was uh.
[AGENT][NEUTRAL] Submitted with us it looks like 12:13.
[AGENT][NEUTRAL] 2024 it looks like we processed the claim on [PII]. Your claim number is 3541821.
[AGENT][NEUTRAL] And that claim had benefits payable of $2000. It looks like that was paid out via check, and your check number is 2018941.
[CUSTOMER][NEUTRAL] Mhm. Oh, Eli.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Actually, I don't see, actually, I have those information with me. OK, so the primary left the total patient's responsibility of, let me just see.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The total patient's responsibility was $4,814 which was submitted to the secondary, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, yeah. Out of which APL.
[CUSTOMER][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] Pay the claim only for 2000.
[AGENT][NEUTRAL] Yes, $2000 and it says on that explanation of benefits, um, that with the payment of this check, um, the calendar year benefits have been met and it looks like your patient has an outpatient calendar year benefit maximum of $2000 so that is their total outpatient benefits with our policy.
[CUSTOMER][NEUTRAL] OK. So, the member has a total out of pocket expenses with APL as of [PII] which was mm.
[CUSTOMER][NEUTRAL] Met with this claim.
[AGENT][NEUTRAL] Yes, so they have their total benefit amount with us was the $2000 and with the payment of this claim they met that benefit, so they maxed out their outpatient benefits with us.
[CUSTOMER][NEUTRAL] OK, just just give me a moment.
[AGENT][POSITIVE] Oh, take your time.
[CUSTOMER][NEUTRAL] OK. So, as you stated that the member had a total out of expenses.
[CUSTOMER][NEUTRAL] OK, just a moment. I have to document that number here.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So for the
[CUSTOMER][NEUTRAL] rest balance of the amount, the rest balance should be billed to the member, right?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, so APL can't determine patient responsibility, so that's gonna be up to the provider's office what to do with the remaining balance.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] From April, there is no.
[CUSTOMER][NEUTRAL] Patients responsibility for the member. It's just that the out of pocket expenses has met.
[AGENT][NEUTRAL] Yeah, we're
[AGENT][NEUTRAL] So we're a supplemental policy so we cannot determine patient responsibility um we don't.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We don't negotiate charges or anything like that so um all we can do is pay benefits payable, which we did in the remaining of the balance, um, that's up to the provider's office to to make decisions after that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, perfect. Can I get the call reference number?
[AGENT][NEUTRAL] Oh, you betcha. The call reference number is my name, [PII], first initial last name, [PII], and then today's date.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][POSITIVE] Thank you so much, [PII], for that information and I wish you a great day ahead.
[AGENT][POSITIVE] Oh yeah my pleasure thank you [PII] and you take care and have a wonderful day.
[CUSTOMER][POSITIVE] Bye-bye. Take care.
[AGENT][NEUTRAL] Bye bye.