AccountId: 011433970860
ContactId: 40503f49-7a6a-4269-b918-e130772b9515
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 438540 ms
Total Talk Time (AGENT): 249711 ms
Total Talk Time (CUSTOMER): 103470 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/30/40503f49-7a6a-4269-b918-e130772b9515_20250130T16:37_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] and I'm calling from provider office looking for a claim status.
[AGENT][NEUTRAL] OK, you said your name was [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, can I get a good call back number for you, [PII]?
[CUSTOMER][NEUTRAL] Yes, it's [PII]. It's a direct line.
[AGENT][NEUTRAL] OK, and what provider's office are you calling with?
[CUSTOMER][NEUTRAL] I am calling from Saint Joseph Center.
[AGENT][NEUTRAL] OK, and for that claim status, do you have your patient's policy number?
[CUSTOMER][NEUTRAL] Yes, I have.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Can I get that number, please?
[CUSTOMER][NEUTRAL] Yeah, it's 02491150.
[AGENT][NEUTRAL] OK, give me just one moment to get that pulled up.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, can you verify the name and date of birth, please?
[CUSTOMER][NEUTRAL] Sure. Remember, first name is [PII], the last name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, and what is the date of service and build amount that we're looking for?
[CUSTOMER][NEUTRAL] Yeah, the date of service is [PII]. Total charge $1,665 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Give me just one moment, let me see what I can find.
[AGENT][NEUTRAL] OK, let's see it looks like I have this claim.
[AGENT][NEUTRAL] Possibly more than once, but let me double check.
[AGENT][NEUTRAL] OK, I do have it more than once. OK, so the first claim we received, um.
[AGENT][NEUTRAL] Was on claim number 351.
[AGENT][NEUTRAL] 70.
[AGENT][NEUTRAL] 92.
[AGENT][NEUTRAL] Um, we received that claim, let's see.
[AGENT][NEUTRAL] We received that on [PII].
[AGENT][NEUTRAL] Of [PII].
[AGENT][NEUTRAL] And we processed it on [PII].
[AGENT][NEUTRAL] And there was a paid amount of $50.
[AGENT][NEUTRAL] And that was on check number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That, uh, payment detail I have.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh what about the second claim that we don't have?
[AGENT][NEUTRAL] OK, so the second claim we received, it was claim 352-402-3, um, it looks like it was the exact same information so it was denied as a duplicate.
[CUSTOMER][NEUTRAL] But uh,
[CUSTOMER][NEUTRAL] As you know, the bill charge was $1,665. And as per our system, we are expecting for the payment of $765.
[CUSTOMER][NEGATIVE] $5.90 and we just received the $50. So according to us, the claim is underpaid.
[AGENT][NEUTRAL] OK, I understand that um.
[CUSTOMER][NEUTRAL] Is there any specific reason?
[AGENT][NEUTRAL] Yes, so this is a limited benefit indemnity plan. Um, it does not hold contracts with any type of insurance or provider. Um, it is basically a supplemental top plan, um, and their benefits are set and limited in nature.
[AGENT][NEUTRAL] And so for an ER visit under this policy, the maximum payable per day is only $50 because like I said, this is not major medical, it's an indemnity plan. So there is no additional benefit that would be payable as that is their benefit. We paid the maximum for this particular day.
[CUSTOMER][NEUTRAL] OK. Can we appeal on it?
[AGENT][POSITIVE] Yeah, you're welcome to appeal.
[CUSTOMER][NEUTRAL] Or it would be
[CUSTOMER][NEUTRAL] OK. Uh, so you can't send back claim for the review without any appeal.
[AGENT][NEUTRAL] That's, that's correct, um, because that is the only benefit available and that is the maximum payable for this particular benefit, um, or services, um, there would not be any reason for us to send it back um there would have to be an appeal to submit it for any additional review um again it does not adhere to contracts or any type of.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Regular major medical top coverages, it is limited benefits, so.
[CUSTOMER][NEUTRAL] OK. Mm.
[CUSTOMER][NEUTRAL] OK. And uh what uh documents do you require in the appeal, the medical records?
[AGENT][NEUTRAL] Um, it
[AGENT][NEUTRAL] If, if you want to you can yeah but mainly we need a um a letter of appeal on the facilities letterhead um stating why you're appealing the claim and then they would move they would review what was submitted um whether you submit additional documentation or not they would review what we've received versus what your claim for the appeal is in the letter.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And based on that information um they would either agree with our judgment and send you information stating that no no steps will be taken further or they'll send you something that says OK we've reviewed it there is additional benefits and this is gonna be processed so they would let you know whether the appeal will move forward with reprocessing or whether the um.
[AGENT][NEUTRAL] The payment of $50 is upheld with no additional benefits.
[CUSTOMER][NEUTRAL] OK. Uh, can you please provide me the address?
[AGENT][NEUTRAL] Sure, so it's gonna be um attention [PII].
[AGENT][NEUTRAL] And it's gonna be [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that is in [PII] City, [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] OK, perfect. Can you please provide me the reference number to this call?
[AGENT][NEUTRAL] Sure, it's just gonna be my name, so that's [PII] with today's date. Is there anything else I can do for you, [PII]?
[CUSTOMER][POSITIVE] No, that's all for today. Thank you.
[AGENT][POSITIVE] You're very welcome have a great day and thanks for calling APO.
[CUSTOMER][NEUTRAL] You too.
[AGENT][NEUTRAL] Bye bye.