AccountId: 011433970860
ContactId: 2ccfce7d-afcf-4347-ac89-25af83739246
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 308260 ms
Total Talk Time (AGENT): 158266 ms
Total Talk Time (CUSTOMER): 100211 ms
Interruptions: 0
Overall Sentiment: AGENT=1.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/16/2ccfce7d-afcf-4347-ac89-25af83739246_20250116T13:50_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good Morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling from provider's office. I'm looking for claims.
[AGENT][POSITIVE] [PII], it would be my pleasure to assist you this morning with claims. What is the callback number, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, [PII]. And what is the policy number for the patient?
[CUSTOMER][NEUTRAL] 02476613
[AGENT][NEUTRAL] Thank you and the patient's name and date of birth, please, ma'am.
[CUSTOMER][NEUTRAL] [PII], date of birth, [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] And I can certainly help you with that claim status. What is the data service?
[CUSTOMER][NEUTRAL] It's [PII]. The bill amount is $9,945.
[AGENT][NEUTRAL] All right, and that is a facility charge. What is the name of the facility?
[CUSTOMER][NEUTRAL] Surgery Center of Fairfield County.
[AGENT][POSITIVE] All right, thank you.
[CUSTOMER][NEUTRAL] Fairfield County.
[AGENT][NEUTRAL] All right, thank you. Now [PII], I am showing that we received that claim on [PII], 2024.
[AGENT][NEUTRAL] It was processed and paid on [PII] 24 in the amount of $808.12.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, wait a second. Could you please repeat your received it on what date?
[AGENT][NEUTRAL] On [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And processed on [PII].
[CUSTOMER][NEUTRAL] OK. Yeah, go ahead.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Paid the benefit amount of $808.12.
[AGENT][NEUTRAL] The surgery center at Fairfield County.
[CUSTOMER][NEUTRAL] OK. And how much are you allowed?
[AGENT][NEUTRAL] Now this is a secondary policy. There's no contractual involvement in the processing we only pay the benefit amount.
[CUSTOMER][NEUTRAL] OK, to secondary policy, so you only paid benefit amount.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] So you're allowed as per the, you're allowed amount as per the primary, right?
[AGENT][NEUTRAL] We pay toward the deductible, co-pay or co-insurance of the major Medical.
[CUSTOMER][MIXED] OK, but as for the primary insurance, they left $1620.90 but you only paid $808.12 out of which, why?
[AGENT][NEUTRAL] That is correct, because the calendar year max benefit for
[AGENT][NEUTRAL] Um, outpatient services is $1000 per calendar year. Now, we received a claim prior to your claim.
[AGENT][NEUTRAL] And we're able to make some payments, leaving the benefit amount available when we receive this claim of $808.12 which was paid to the facility.
[CUSTOMER][NEUTRAL] OK. So the patient's maximum benefit was met already, right?
[AGENT][NEUTRAL] With the payment of this claim, the maximum benefit is met.
[CUSTOMER][NEUTRAL] With the payment of this claim.
[CUSTOMER][NEUTRAL] Maximum benefit.net, right?
[AGENT][NEUTRAL] So
[AGENT][POSITIVE] That's right. With the, with this payment, it maxed out the benefits. We paid the remaining benefits payable to Surgery Center in [PII].
[CUSTOMER][NEUTRAL] OK. And uh
[CUSTOMER][NEUTRAL] OK. And it, in terms of dollar value, right, which is $1000 per calendar year.
[AGENT][POSITIVE] Yes, ma'am. That is correct.
[CUSTOMER][NEUTRAL] OK, so you paid $808.12 sir, which completed the amount of $1000 right?
[AGENT][POSITIVE] That's right, yes, ma'am.
[CUSTOMER][NEUTRAL] OK. And will, OK, it's met on what date?
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Um, 9 the maximum was paid on this claim on [PII] for the data service 723.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So you are not gonna pay, right? Extra amount.
[AGENT][NEUTRAL] That's right, because it maxed out the benefits. There's no benefits remaining after this payment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's a patient responsibility, the left amount, right?
[AGENT][NEUTRAL] Oh, no, we don't determine patient responsibility because we're secondary, so that would be determined by the provider and major medical.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. What's the reference number?
[AGENT][NEUTRAL] Reference number is my name and today's date, and I spell my name [PII], it was a pleasure to assist you with that claim status. Is there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, just this. Thank you so much, [PII]. Thanks for the help. Bye for now.
[AGENT][NEUTRAL] Mm