AccountId: 011433970860
ContactId: 4ee5774b-44a7-4a83-93cc-1c45619d3cc6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 390079 ms
Total Talk Time (AGENT): 160637 ms
Total Talk Time (CUSTOMER): 111936 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/18/4ee5774b-44a7-4a83-93cc-1c45619d3cc6_20250418T15:02_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, hi, my name is [PII], and I'm calling from the provider's office. I'm looking for some claims information.
[AGENT][NEUTRAL] OK, I could check on a claim for you. I'm sorry, what did you say your name was?
[CUSTOMER][NEUTRAL] It's [PII] on [PII].
[AGENT][NEUTRAL] OK and then can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] Yes, give me one moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] 01868848
[AGENT][NEUTRAL] OK, and then what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] This is about uh.
[CUSTOMER][NEUTRAL] [PII] and uh [PII].
[AGENT][POSITIVE] Perfect, thank you for verifying that and uh what was the date of service for this claim please?
[CUSTOMER][NEUTRAL] Yes, one night of [PII] and $14,992.
[AGENT][NEUTRAL] OK thank you one moment please.
[AGENT][NEUTRAL] OK, do you have the amount uh that was left over after major medical paid?
[CUSTOMER][NEUTRAL] Yes, uh, the claim is paid, uh, this claim is paid for $2550 and uh.
[CUSTOMER][NEUTRAL] I think you you have the same information.
[AGENT][NEUTRAL] OK, yes, just wanted to verify that we did receive that EOB. OK, one moment please.
[AGENT][NEUTRAL] Was this, uh, is it VHS Brownsville Hospital?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so the amount after major medical was uh $2,887.46 is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Awesome, OK, yes, so I found this claim, uh, that amount that we paid the $2550 that did meet their maximum benefit amount, so that was the most we were able to pay.
[CUSTOMER][NEUTRAL] Mhm, right, what we found, uh, we have the contract uh documents and we found this claim is underpaid for some amount of uh.
[CUSTOMER][NEUTRAL] Give me one moment. It's uh $337.46 because uh
[CUSTOMER][NEUTRAL] The expected reimbursement for this claim should be $2,887.46.
[AGENT][NEUTRAL] Correct, however, the payment that we did make met their maximum. That was the maximum amount we could pay was that $2550.
[AGENT][NEUTRAL] So their their benefit amount had been exhausted with that payment.
[CUSTOMER][NEUTRAL] Uh, give me one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. So, I need the address for this submission because from our end, uh, this claim is still underpaid and uh we are looking for the additional payment. So I need the address for bill submission and timely filing also fax number if you have any.
[AGENT][NEUTRAL] So I can, I'm more than happy to send you a copy of this EOB that does state this was the maximum amount that we could pay. I understand that the amount was for $2,887.46. However, their outpatient benefit amount, uh, there is a limit on how much we can pay, and that $2550 met that limit.
[CUSTOMER][NEUTRAL] Yes, so I'm not, uh, I'm, so I need, uh, still we needed that bill address and, uh, fax number also timely filing.
[AGENT][NEUTRAL] OK, sure, so that information is all going to be the same for regular claims, but I can still give that to you as far as timely filing for appeals that would be within 180 days of the process date, which that was [PII].
[AGENT][NEUTRAL] And whenever you're ready I can give you that um address and fax number if you don't have that.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Yes, I'm ready.
[AGENT][NEUTRAL] OK, uh, address is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And your fax number?
[AGENT][NEUTRAL] That is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII] 3.
[CUSTOMER][NEUTRAL] OK, so I need your reference number for this call and I'm sorry I didn't catch your name.
[AGENT][NEUTRAL] That's OK. The reference number would just be my first name, last initial, and today's date, and so my name is spelled [PII] Was there anything else I could help you with?
[CUSTOMER][NEUTRAL] So this is the reference number, right? Your name and uh today's date.
[AGENT][NEUTRAL] Yes, my first name, last initial, and today's date.
[CUSTOMER][POSITIVE] OK. That's it because I have only one member today and uh thank you for providing me this information. You have a wonderful time. Thank you. Bye-bye.
[AGENT][NEUTRAL] Of course.
[AGENT][POSITIVE] Thanks for giving us a call, yes, have a great weekend bye bye.