AccountId: 011433970860
ContactId: 4a57a777-24dc-474a-9c1a-6125b9d8ed4e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 674109 ms
Total Talk Time (AGENT): 168300 ms
Total Talk Time (CUSTOMER): 185148 ms
Interruptions: 4
Overall Sentiment: AGENT=1.1, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/28/4a57a777-24dc-474a-9c1a-6125b9d8ed4e_20250528T14:40_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, this is [PII] calling from our office to checking for client status.
[AGENT][NEUTRAL] OK, [PII], I can help you with claim status. May I please get your callback number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And then what is the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Policy number 02334372 member's name was [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][NEUTRAL] OK, let me look that up real quick.
[CUSTOMER][NEUTRAL] OK, let me
[AGENT][NEUTRAL] OK, and then may I please have the data service and the charge amount?
[CUSTOMER][NEUTRAL] 224 of [PII].
[AGENT][NEUTRAL] That's [PII].
[CUSTOMER][NEUTRAL] With the total charges 21.
[CUSTOMER][NEUTRAL] It's 2025 2 24 2025.
[CUSTOMER][NEUTRAL] With the total charges $261.
[AGENT][NEUTRAL] OK, and then what are the charges after the primary paid their part?
[CUSTOMER][NEUTRAL] Uh, primary has paid $142.11 with patient responsibility $35.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And may I please have the name of the facility you're calling for?
[CUSTOMER][NEUTRAL] Yep
[CUSTOMER][NEUTRAL] Prima Health.
[AGENT][NEUTRAL] All right, Miss [PII], I'm going to put you on a brief hold while I look up this claim for you and I'll be right back, ma'am.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding for me, Miss [PII]. So looking on data service of [PII] for [PII], I do not find a claim on file.
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] Uh, February
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What is the uh members effective and termination date?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] The effective date of the policy is [PII] and the policy is still active.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. What is an uh pay uh mailing address for submitting claims?
[AGENT][NEUTRAL] That would be [PII].
[AGENT][NEUTRAL] That's in [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, what is the payer ID?
[AGENT][NEUTRAL] 60801.
[CUSTOMER][NEUTRAL] 6
[CUSTOMER][NEUTRAL] Timely filing to submit the claim.
[AGENT][NEGATIVE] We do not have a timely filing limit.
[CUSTOMER][NEUTRAL] We did
[CUSTOMER][NEUTRAL] What is the call reference number for this, and can you please tell me your name again?
[AGENT][NEUTRAL] Yes ma'am, you can use my name [PII] and today's date for your reference.
[CUSTOMER][NEUTRAL] Oh, I do have one more client with a different patient.
[AGENT][NEUTRAL] OK, and what is the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] The policy number for this patient 1237335.
[CUSTOMER][NEUTRAL] Member's name
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII] with date of birth [PII].
[AGENT][NEUTRAL] OK, thank you, and then may I have the data service and the charge amount?
[CUSTOMER][NEUTRAL] [PII] and the charge amount uh $2,685.
[AGENT][NEUTRAL] OK, and what are the charges after the primary paid their part?
[CUSTOMER][NEUTRAL] Uh, primary supplied to the deductible $2,542.
[CUSTOMER][NEUTRAL] And the insurance has
[AGENT][NEUTRAL] OK, and, and
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But you only paid $500.
[AGENT][NEUTRAL] OK, and then what's the name of the facility for this one?
[CUSTOMER][NEUTRAL] Same for my health.
[AGENT][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Alright, I'm gonna put you on a quick hold while I look up this one and I'll be right back with you.
[CUSTOMER][NEUTRAL] Like.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] PD
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding for me. I do have the claim.
[AGENT][NEUTRAL] Available, the claim number is 3553013.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] A
[CUSTOMER][NEUTRAL] Yes, I have the.
[CUSTOMER][NEUTRAL] Once again, I have the claim details for this claim. As we check, there is no denial on that. But however, the claim is not uh with the expected amount.
[AGENT][POSITIVE] Oh good.
[AGENT][NEUTRAL] Right, because according to this policy,
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] They have an outpatient maximum benefit amount and this is just to verify benefits it's not a guarantee of payment.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] an outpatient.
[CUSTOMER][NEUTRAL] Just to verify that if I give you a payment.
[AGENT][NEUTRAL] Of only $500 per calendar year. So after the payment, the benefit was maxed out for the calendar year.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] For outpatient claims, uh, the American Life Insurance only allows $500 with the current year.
[AGENT][NEUTRAL] On this member's policy.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh, as per the guidelines for this policy, it only allows $500 right?
[AGENT][POSITIVE] Correct. Yes, ma'am.
[CUSTOMER][NEUTRAL] For this claim, what we have to do, we need to submit an update.
[AGENT][NEUTRAL] No, the policy, the claim has been paid.
[CUSTOMER][NEUTRAL] the question has been.
[AGENT][NEUTRAL] According to the insured's plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, for the remaining balance is patient responsibility.
[AGENT][NEUTRAL] We don't give patient responsibility. We let the provider determine that.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're very welcome.
[CUSTOMER][POSITIVE] Have a great day.
[AGENT][POSITIVE] You have a wonderful day too, and thank you for calling APL.
[CUSTOMER][NEUTRAL] Mhm bye bye.
[AGENT][NEUTRAL] Bye-bye.