AccountId: 011433970860
ContactId: 3d6d8be6-dc00-499f-80df-be570446dc5f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 459040 ms
Total Talk Time (AGENT): 199184 ms
Total Talk Time (CUSTOMER): 137346 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/3d6d8be6-dc00-499f-80df-be570446dc5f_20250210T18:56_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. My name is [PII]. May I get your last initial, please?
[AGENT][NEUTRAL] Sure, it's [PII].
[CUSTOMER][POSITIVE] Thank you. I have a claim that has been processed and I have a question about the benefits that were applied.
[AGENT][NEUTRAL] OK, well, I can definitely help you with the claim and you're calling from a provider's office or a group?
[CUSTOMER][NEUTRAL] Facility.
[AGENT][NEUTRAL] OK, and may I have a good contact number in case we're disconnected and then the member's policy number?
[CUSTOMER][NEUTRAL] Alright, my number is [PII].
[CUSTOMER][NEUTRAL] [PII] and that's a direct line um.
[CUSTOMER][NEUTRAL] Policy number is 196.
[CUSTOMER][NEUTRAL] 792-2.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] Thank you for that and may I have the date of service or the claim number for the claim you'd like me to look at?
[CUSTOMER][NEUTRAL] Yeah, the claim number is 3546728.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Data service [PII].
[AGENT][NEUTRAL] And again just for the call, all the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment while I look for the claim.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] 728. You're welcome.
[AGENT][NEUTRAL] 672 8. OK, here it is.
[AGENT][NEUTRAL] All right, I just located the claim. Hold on one moment.
[CUSTOMER][POSITIVE] All right, you're fine, thank you.
[AGENT][NEUTRAL] OK, so the claim was denied because the maximum benefit for the calendar year was exhausted. OK. And um what questions did you have?
[CUSTOMER][NEGATIVE] I need to get the date of the maximum benefits we're exhausted.
[AGENT][NEUTRAL] What's the, hold on one second.
[CUSTOMER][NEUTRAL] And if you can while you're doing that, if it tells you what kind of policy this is.
[AGENT][NEUTRAL] So this is a hospital indemnity policy, it's a limited medical policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, I'm gonna look and see what the benefit is that was applied, um, and if the claim that paid out or that exhausted this benefit is your provider's claim. If not, I can't give you their claim status, but hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] $75 up to $5 per calendar year, OK.
[CUSTOMER][NEUTRAL] So it pays $75 a visit and 5 times a year.
[AGENT][NEUTRAL] Mhm. So by the time yours came in, they used their 5 visits for the year. And it doesn't just have to be emergency room. This could be doctor's office.
[AGENT][NEUTRAL] Um, any claims that are processed under outpatient, that's enough.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, office setting.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Was he confined at any time or was she confined at any time?
[CUSTOMER][NEUTRAL] No, we have about 8, we have, we have about 6 months of once a month ER visits.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, so just looking at what, what is this data service? Hold on one second.
[CUSTOMER][NEUTRAL] It was [PII].
[AGENT][NEUTRAL] No, no, not this one. Hold on one moment. I'm looking for the.
[CUSTOMER][NEUTRAL] Oh, OK, OK.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Sorry.
[AGENT][NEUTRAL] It's OK.
[AGENT][NEUTRAL] Is this the same one.
[AGENT][NEUTRAL] 725 here it is.
[AGENT][NEUTRAL] Um, the date the claim was processed that exhausted the five visits was [PII].
[CUSTOMER][NEUTRAL] Well this is a 24 bill.
[AGENT][NEUTRAL] Right, the date that I'm not giving you the data service.
[CUSTOMER][NEUTRAL] Oh, what's her calendar year? What's her calendar year then?
[AGENT][NEUTRAL] The calendar year is January to January.
[AGENT][NEUTRAL] A plan year would be like the effective date, but
[CUSTOMER][NEUTRAL] It be January to December.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So is it and it's calendar year you said that that would be a different calendar year.
[CUSTOMER][NEUTRAL] Or that's the date the claim, that's our claim though, isn't it? Wait a minute let me see something.
[AGENT][NEUTRAL] This is the, this, I'm giving you the date the claim was processed, not the date of service. The date of service is what
[AGENT][NEUTRAL] Determines the calend that is affected by the calendar year. I
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Let me see if this is your, if this, what's your tax ID?
[CUSTOMER][NEUTRAL] It is my claim.
[CUSTOMER][NEUTRAL] Yeah, it is our claim we we we show that it processed on [PII]. Our tax ID is [PII].
[AGENT][NEUTRAL] OK, so no, this is a different provider. It is just the same day, it's just the same processing date. So this is a different provider, but
[AGENT][NEGATIVE] That's the day that the claim was processed that exhausted this benefit.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, does she have, uh, can you give me her dates of eligibility and if she has a group number what that would be, please?
[AGENT][NEUTRAL] Mhm. So the policy has been active since [PII].
[AGENT][NEUTRAL] It's still active.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then, what was the second question?
[CUSTOMER][NEUTRAL] Does she have a group number?
[AGENT][NEUTRAL] The group number is 70056.
[CUSTOMER][NEUTRAL] OK, alright, and can I verify the claims address? We did get a payment back. I think we built it through 90 Degrees and I don't know what your relationship is to them.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, the claims, well, we work with 90 Degree, but if you sent the claims, it should have been sent to [PII].
[AGENT][NEUTRAL] In [PII]? Yeah, that's the correct address.
[CUSTOMER][NEUTRAL] That's who we sent it to.
[CUSTOMER][NEUTRAL] Yeah, that's the correct claims address, OK, because the EOB we got from you guys has an [PII] address. I didn't know which was the correct address.
[AGENT][NEUTRAL] Oh, both. So IMA is kind of like re-pricing and then it's sent to us to finish out the finalizing of the claim, so it's both.
[CUSTOMER][POSITIVE] OK, OK, OK, alright, thank you for your help and all your patience with my questions. Can I get a call reference number from you?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name, which is [PII], first initials and my last name is [PII], and today's date.
[CUSTOMER][POSITIVE] Oh, all right, thank you so much. Hope you have a good afternoon.
[AGENT][POSITIVE] You're welcome, [PII]. You also, and thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Mhm bye bye.