AccountId: 011433970860
ContactId: 503dd420-4b4e-435b-949e-b6716d406001
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 539840 ms
Total Talk Time (AGENT): 247263 ms
Total Talk Time (CUSTOMER): 154869 ms
Interruptions: 3
Overall Sentiment: AGENT=0.2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/18/503dd420-4b4e-435b-949e-b6716d406001_20250618T14:49_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh, hi, I'm [PII] calling on behalf of providers Hospital to check on a claim status. Could you spell me your name, please?
[AGENT][NEUTRAL] Sure, my name is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And did you say your name was?
[CUSTOMER][POSITIVE] Yes, thank you. I want to check on a claim status.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] You said your name was [PII]?
[CUSTOMER][NEUTRAL] No, [PII].
[AGENT][NEUTRAL] I'm sorry, I'm sorry. Can you speak slowly, please? Can you repeat that?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and [PII], um, may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, sure. The contact number is [PII].
[AGENT][NEUTRAL] And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Only one claim.
[AGENT][NEUTRAL] All right, and the members.
[CUSTOMER][NEUTRAL] The policy number
[CUSTOMER][NEUTRAL] Yeah, D as in Delta, 43,510,820.
[AGENT][NEUTRAL] And do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] Uh yeah, sure.
[AGENT][NEUTRAL] On the ID card, do you see anywhere that says inhospital or outpatient policy cert number? It should start with a 01 or 02.
[CUSTOMER][NEUTRAL] Uh, just trying to, I could check here.
[CUSTOMER][NEUTRAL] Mm, uh, I have only claim number.
[AGENT][NEUTRAL] OK, what's the claim number that you have?
[CUSTOMER][NEUTRAL] 354-547-3.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, patient name is [PII] and the date of birth is [PII]. It's [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So the policy number is 2558899.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Sorry? Could you repeat that?
[AGENT][NEUTRAL] I'm giving you the policy number for the for APL for this member.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The policy number is 255.
[AGENT][NEUTRAL] 8899.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And hold on one moment while I pull the claim.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, so I'm showing we paid a total of $50 to this claim, and did you have any questions or?
[CUSTOMER][NEGATIVE] Yeah, when was the claim received and processed? Uh, but I expected not met.
[CUSTOMER][NEUTRAL] Because our expected amount is $4439.90 but you have to only pay $50 only. That's why I'm asking.
[AGENT][NEUTRAL] So we received the claim on [PII].
[AGENT][NEUTRAL] We processed the claim on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And let me see, uh.
[CUSTOMER][NEUTRAL] When was the claim paid?
[AGENT][NEUTRAL] Hold on one second, OK?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So as I stated, yes, the claim was paid. We paid a total of $50 to the claim. I'm looking up the benefits to see what benefit was used. Give me just a moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] So for the emergency room, the policy will pay up to $50 per visit 2 times per calendar year. So the $50 was applied to this to this claim.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] The benefit used, the max is $50.
[AGENT][NEUTRAL] 2 times per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The policy will pay towards the emergency room?
[AGENT][NEUTRAL] So that that's why $50 was paid because the max for emergency rooms is $50.02 times per year, so we applied it to this to this claim.
[CUSTOMER][NEUTRAL] Mm OK.
[CUSTOMER][NEUTRAL] Which, which card it got paid?
[CUSTOMER][NEUTRAL] Which CPT code got paid.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There's only one code. It was an ER charge. It it doesn't, it doesn't have a procedure code. It says ER.
[AGENT][NEUTRAL] We were billed $4,439.90.
[CUSTOMER][NEUTRAL] Yeah, because all the CPT codes which have to build that CPT code all are getting that expectation.
[CUSTOMER][NEUTRAL] But only you have to pay only one CVD code.
[AGENT][NEUTRAL] I understand what you were expecting, but the
[AGENT][NEUTRAL] The max that can, the max max mean, go ahead.
[CUSTOMER][NEUTRAL] Our total charge amount.
[CUSTOMER][NEUTRAL] Yeah, yeah, our total, total charges have an expected amount.
[CUSTOMER][NEUTRAL] But your insurance can get paid only one CPD code. But our all CPT codes can have an expectation for this claim.
[AGENT][NEUTRAL] OK, so what I'm trying to explain to you, there's only one code here. It says, and this just says ER.
[AGENT][NEUTRAL] But the reason that the answer to your question, why was $50 paid when we were billed for $1000 the answer is $50 was paid because that is the most that the benefit can pay, that's the max.
[AGENT][NEUTRAL] $50.02 times per year.
[AGENT][NEUTRAL] So the $50 was applied to this claim.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] But that $50 it's allowed for only year charges, am I right?
[AGENT][NEUTRAL] It's for the date of service. So for
[AGENT][NEUTRAL] [PII] is the date of service. So whether the bill was a million dollars or $1 we can only apply $50.
[AGENT][NEUTRAL] Because that's the max for the benefit.
[CUSTOMER][NEUTRAL] Can we apply for this one?
[AGENT][NEUTRAL] Um, you, uh, of course, you have the right to an appeal, but if the max, if the most on the claim has been paid, you can't pay more than the most. So it would most likely be denied because we paid the max.
[CUSTOMER][NEUTRAL] Mm, yeah, because our expected not met, that's why I'm asking, can we can you provide me that a fax number, a fax number and uh the mailing address?
[AGENT][NEUTRAL] Sure. So our appeals, um, mailing address, it would go to IMA.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That um mailing address is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And there's a payer ID as well if you like it.
[CUSTOMER][NEUTRAL] No, a fax number, I mean another fax number?
[AGENT][NEUTRAL] There's no fax number for IMA?
[CUSTOMER][NEUTRAL] A fax number.
[CUSTOMER][NEUTRAL] OK. Attention?
[AGENT][NEUTRAL] Attention IMA.
[CUSTOMER][POSITIVE] Great.
[CUSTOMER][NEUTRAL] Payer ID?
[AGENT][NEUTRAL] 64556.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, we can submit appeal only via mail, mailing address. Am I right?
[AGENT][NEUTRAL] Yes, you're free to file the appeal through the mailing address or the payer ID.
[CUSTOMER][POSITIVE] Good
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] May I know the call reference number?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name in today's date, and again, that's [PII], first initials of my last name is [PII].
[CUSTOMER][POSITIVE] Yeah, thank you for your assistance. Have a great day bye for now.
[AGENT][POSITIVE] You also actually, was there anything else I can assist you with today?
[CUSTOMER][NEGATIVE] No, no.