AccountId: 011433970860
ContactId: 59417566-8ddf-4d78-92aa-2de5b5234870
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 509019 ms
Total Talk Time (AGENT): 206833 ms
Total Talk Time (CUSTOMER): 152159 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/22/59417566-8ddf-4d78-92aa-2de5b5234870_20250522T14:31_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I'm calling about a claim that has been processed and I have some questions about that.
[AGENT][NEUTRAL] OK, well, I can help you with your claim. And may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Mhm. My name is [PII] and it's [PII].
[AGENT][NEUTRAL] And are you the insured or you're calling with the provider's office?
[CUSTOMER][NEUTRAL] His father's house.
[AGENT][NEUTRAL] Alright, and may I have um
[AGENT][NEUTRAL] Oops, I'm sorry, I was typing and it didn't type. Can you repeat your name for me, please? Did you say [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, it's D as in David 43732467.
[AGENT][NEUTRAL] OK, do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] I do not have a copy of it, no.
[AGENT][NEUTRAL] Do you have the EOB?
[CUSTOMER][NEUTRAL] I do.
[AGENT][NEUTRAL] What is the policy number on the EOB or the claim number?
[CUSTOMER][NEUTRAL] The claim number is 3555963.
[AGENT][NEUTRAL] Do you see the policy number as well? The D number is for 90 degree benefits, so we can't use that. That's why I'm asking this just.
[AGENT][NEUTRAL] Just
[CUSTOMER][NEUTRAL] Oh, OK, no, it, I don't have that.
[CUSTOMER][NEUTRAL] I'm sorry, I did have, uh, the EOB is paper and I can't, I, I actually can't pull that up so.
[AGENT][NEUTRAL] OK, um, can you repeat the claim number again?
[CUSTOMER][NEUTRAL] Yes, 355-5963.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, I have it here. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Mhm. It is [PII] Date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. Um, let me take a look at this claim. Hold on one moment.
[AGENT][NEUTRAL] OK, it's just the one.
[AGENT][NEUTRAL] OK, um, so the claim was denied because the calendar year max for diagnostic services has been met. And what question did you have?
[CUSTOMER][NEUTRAL] Well, so it made no payment, right?
[AGENT][NEUTRAL] Yes, ma'am, no payment.
[CUSTOMER][NEUTRAL] Uh, OK, but it, so.
[CUSTOMER][NEUTRAL] The whole thing because my notes said that it allowed 100 250.
[CUSTOMER][NEGATIVE] But that means if there's no patient responsibility everything gotta be written off for this.
[AGENT][NEUTRAL] Well, we don't determine patient responsibility, so that would be up to you all as the provider. Um, let me pull up the benefits so I can see what we're working with. Hold on one moment.
[AGENT][NEUTRAL] And his diagnostic. Hold on one moment.
[AGENT][NEUTRAL] OK, so it's 250 per test.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Hold on one moment. I'm just trying to figure this out.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] At 250, yeah. OK.
[AGENT][NEUTRAL] Is this the same provider?
[AGENT][NEUTRAL] Yes, OK, so you all submitted a claim.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Data service, [PII].
[AGENT][NEUTRAL] In which the $250 was paid out for those.
[AGENT][NEUTRAL] Um, for that claim. So it's $250 per person per calendar year. So that when we paid that first initial claim that maxed out that uh diagnostic testing benefit.
[CUSTOMER][NEUTRAL] OK, let me
[CUSTOMER][NEUTRAL] OK, you said what date did you say that that the 250 was paid out?
[AGENT][NEUTRAL] Um, this is [PII]. Wait, I'm sorry.
[AGENT][NEUTRAL] [PII]. I got the numbers mixed up. I'm sorry.
[CUSTOMER][NEUTRAL] OK, and.
[CUSTOMER][NEUTRAL] So it pays $250 for any any I guess radiology.
[AGENT][NEUTRAL] Mhm, because this is
[CUSTOMER][NEUTRAL] And for the member's plan.
[AGENT][NEUTRAL] Right. Um, so this is a hospital indemnity policy, so it pays out for diagnostic testing, $250.
[AGENT][NEUTRAL] Per test, but the max is $250 per calendar year, so that's just one test.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I only see, let's see that we've got 209 between the two that we got paid.
[AGENT][NEUTRAL] For claim, uh, I think.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Well, so it's like this.
[CUSTOMER][NEUTRAL] Is that per provider or is that just overall?
[AGENT][NEUTRAL] No, there were 2 checks totaling $250.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What were those check numbers?
[AGENT][NEUTRAL] Um, 202.
[AGENT][NEUTRAL] 4594.
[AGENT][NEUTRAL] was for $78.
[AGENT][NEUTRAL] And then 2
[CUSTOMER][NEUTRAL] 2024594
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then 2024595 was $172.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, 95. I've got the 95.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I'm gonna have to research those payments but I want to get back to.
[CUSTOMER][NEUTRAL] The benefits, so the patient gets $250 a calendar year.
[CUSTOMER][NEUTRAL] For diagnostic, I guess for radiology.
[AGENT][NEUTRAL] Mhm. For diagnostic testing, yes, ma'am.
[CUSTOMER][NEUTRAL] OK, after the 250s me though, is the balance patient responsibility or do we have to adjust that off?
[AGENT][NEUTRAL] We don't determine that. Um, we're not a major medical insurance company, that's why there's no patient responsibility column on the explanation of benefits. We can't determine that. Um, so if there's an outstanding.
[CUSTOMER][NEUTRAL] Well, how would I determine that because normally the payer is the one that says who bills what you can or cannot bill the patient.
[AGENT][NEUTRAL] Right, if it's a major insurance company, yes, um, but this is not a major medical insurance company, so that would be up to you all. Do you write it off, do you bill, we can't determine that for you.
[CUSTOMER][NEUTRAL] No, we can bill the patient OK alright and what's the reference number?
[CUSTOMER][NEUTRAL] For our account.
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name and today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, thank you, [PII]. You have a good day.
[AGENT][POSITIVE] You're welcome, [PII]. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, that's all, thank you.
[AGENT][POSITIVE] Alright, thanks for calling APL bye bye.