AccountId: 011433970860
ContactId: 29716ed8-9741-4436-acac-f84b96459227
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 303720 ms
Total Talk Time (AGENT): 101553 ms
Total Talk Time (CUSTOMER): 134844 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/29716ed8-9741-4436-acac-f84b96459227_20250109T14:10_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling Atel [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, uh, this is [PII] from Medsure calling regarding a claim.
[AGENT][NEUTRAL] Hey, [PII], I can help you with that. Can I get a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] The policy number.
[CUSTOMER][NEUTRAL] Oh, that's a good question. Uh, 02337796.
[AGENT][NEUTRAL] The member's name, date of birth.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh, name is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] OK, [PII], thank you for that. You said you wanted a claim status?
[CUSTOMER][NEGATIVE] Uh, yes, I'm wanting to know uh why it denied.
[AGENT][NEUTRAL] And what's the data service?
[CUSTOMER][NEUTRAL] 5 10 2024.
[AGENT][NEUTRAL] And what's the claim number?
[CUSTOMER][NEUTRAL] The claim number oh that's.
[CUSTOMER][POSITIVE] Another very good question.
[AGENT][NEUTRAL] And we'll start with the 3.
[CUSTOMER][NEUTRAL] There it is, OK, hold on.
[CUSTOMER][NEUTRAL] We attached it but I have to look for the.
[CUSTOMER][NEUTRAL] 352-693-9.
[AGENT][NEUTRAL] OK, so this is for ambulance.
[CUSTOMER][NEUTRAL] Yes, it is.
[AGENT][NEUTRAL] OK, so this claim denied because the member has their um inpatient benefit for the year.
[CUSTOMER][NEUTRAL] So is this like a um accident.
[CUSTOMER][NEUTRAL] Insurance plan or like an.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] So this was um this was a gap policy, so it was secondary to the members primary.
[CUSTOMER][NEUTRAL] Or is it just the basic commercial?
[CUSTOMER][NEUTRAL] OK, and do you mind me asking, like, um, so is this, do you guys cover emergency services and is this a type of plan that only covers to like let's just say 10,000, so you cover up to 10,000 and then it it's cut off, so they're they're.
[AGENT][NEUTRAL] So they have a
[CUSTOMER][NEUTRAL] Their expenses were are you do you guys only cover inpatient expenses?
[AGENT][NEUTRAL] No, so, um, the policy covers for several things, um, but once the member meets their allot amount on their policy, um, we can't pay anymore. So, um, so as far as this one goes, so the member's inpatient benefit, I'm getting that for you right now. Give me one second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So the members inpatient benefit pays up to $2500 per calendar year. So we had already paid that out before we, we received the claim for the ambulance. Um, we received the claim for inpa, the actual hospital and for other professional and that maxed out that benefit for the year.
[AGENT][NEUTRAL] So whatever charges you are charging for the ambulance that will go to patient responsibility.
[CUSTOMER][NEUTRAL] All right, and uh one more question, so you're stating inpatient stay but um the an ambulance trip isn't technically inpatient we're.
[CUSTOMER][NEUTRAL] We're just transporting the patient, so we're we're deemed as um.
[CUSTOMER][NEUTRAL] More of an outpatient emergency, uh.
[CUSTOMER][NEUTRAL] It's all medically necessary. Does that make a difference or is ambulance with your company just deemed inpatient due to the emergency taking place?
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] So, it's normally outpatient. However, um, per the policy, if the member is admitted to the hospital as an inpatient, it turns over to inpatient.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] So if they were not, so just if they went to the ER and they were not admitted um to the hospital, then it would, it would have been processed on the outpatient.
[CUSTOMER][NEUTRAL] OK, I'm just trying to think of a scenario that would consider it an outpatient now.
[CUSTOMER][NEUTRAL] OK, um, well I think that's all that I needed. Do you give out reference numbers?
[AGENT][NEUTRAL] We don't, you can use my name on today's date.
[CUSTOMER][NEUTRAL] What's the uh what's your name again?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] There you
[CUSTOMER][POSITIVE] All right thank you so much [PII] you have a wonderful rest of your day.
[AGENT][NEUTRAL] Yes, so, [PII], was there anything else that I can help you with today?
[CUSTOMER][POSITIVE] No, no, you helped me with everything thank you.
[AGENT][POSITIVE] No problem, thanks for calling April