AccountId: 011433970860
ContactId: 5d6d3a36-5262-49ec-badc-4ad38adfcff0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 705669 ms
Total Talk Time (AGENT): 298638 ms
Total Talk Time (CUSTOMER): 183803 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/5d6d3a36-5262-49ec-badc-4ad38adfcff0_20250123T14:20_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] calling on behalf of provider offer checking on a claim status.
[AGENT][NEUTRAL] Sure I can help you with the claim status. [PII], can I have a callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. Callback number I have is [PII].
[CUSTOMER][NEUTRAL] [PII] with the extension of [PII].
[AGENT][NEUTRAL] Thank you [PII] and I'm sorry, can you tell me the name of the provider or facility you're calling from?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, this is for Holy Cross Hospital.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And go ahead with that uh.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Go ahead with that uh policy certificate or member ID please.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Policy ID starts with 01881588 M as in Mike L as in Larry, number 8.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And just give me one moment to pull up that policy. I'll have you verify patient's name and date of birth please.
[CUSTOMER][NEUTRAL] This is for [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and may I please have the date of service and the amount on the claim, [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] This is for [PII].
[CUSTOMER][NEUTRAL] And I have a charge amount of $2,525.10.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Just give me one moment to search claims please.
[CUSTOMER][POSITIVE] Please take your time.
[AGENT][NEUTRAL] OK, I'm gonna pull a claim image that'll take just a moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Just bear with me for just one moment. I'm waiting for the system to load.
[AGENT][NEUTRAL] Excuse me.
[CUSTOMER][POSITIVE] It's all right, [PII]. Please, uh, take your time.
[AGENT][NEUTRAL] OK, so just verifying data service [PII] our total charges that were billed.
[AGENT][NEUTRAL] 2,525 and 10 cents.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Perfect, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I believe I have that claim information.
[AGENT][NEUTRAL] Just bear with me for one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so that claim detail.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We have the claim received date of [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, I'm sorry, my, my apologies, just one moment.
[CUSTOMER][POSITIVE] It's all right. Please take it.
[AGENT][NEGATIVE] That's the wrong claim line
[AGENT][NEUTRAL] OK, I think I got it now. She has a lot of claims, my apologies. OK, so claim receive date is [PII].
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We process the claim on [PII] finalized [PII]. Claim number 35.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 30
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 235.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it looks like we made a benefit payment of 2409.
[AGENT][NEUTRAL] Under that claim number.
[AGENT][NEUTRAL] Was this a corrected claim? Let me see.
[AGENT][NEUTRAL] 235.
[CUSTOMER][NEUTRAL] Uh, actually, uh, this is, uh, secondary claim, and I just wanna know like, uh, have you received the primary claim on this?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Because, uh, primary has processed this claim and uh there was a patient responsibility on the claim with uh $275.91.
[CUSTOMER][NEUTRAL] But uh when I see the UB, I do see there was a payment of $24.09.
[AGENT][NEUTRAL] Yeah, and I do have an additional claim. Let me see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm gonna look at this other claim, so bear with me for just a moment.
[CUSTOMER][POSITIVE] Mhm. Please take your time.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, that looks like it's professional fee.
[AGENT][NEUTRAL] OK, so it does appear that um.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so I was just checking some additional information, so they have a per calendar day maximum. OK, so what happened is, um, when we received that claim, uh, we, we made that benefit payment of $24.09 so they have a, um, this policy is secondary to their major medical, so it does cover co-insurance and deductible amounts for services covered under the plan.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] However, they do have a per calendar day maximum of $300 allowed and so what that means is that's the maximum benefit that's payable per day. So we did receive uh additional claims for that same data service they they appear to be like professional fees.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So what happened is that um that those claims were paid which left that remaining amount which in this situation was only the $24.09 so that's why that benefit payment was 2409. Now do you need the check number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] One moment, let me document that, uh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Makes sense. Uh, so that, uh, the patient, uh per day maximum was $300. And uh do you have the information to which, uh, like, you know, to relevant claim that was been received? Do you have that claim number?
[AGENT][NEUTRAL] The claim number for the the payment made to you.
[CUSTOMER][NEUTRAL] Not me, like, you know, for the different vendors uh.
[CUSTOMER][NEUTRAL] Uh, I have a different claim. I'm asking.
[AGENT][NEUTRAL] Um, well, because it's not your claim, I can't give you that claim information. It's not your claim from your facility, um, however, like they were, they were different.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Oh, so.
[CUSTOMER][POSITIVE] It was from, it was not from our purchase. OK, makes sense. Now it [PII]kes sense. Thank you so much for that, uh, information.
[AGENT][NEUTRAL] Um, well, this actually this particular one, let me, let me double check on this 140.
[AGENT][NEUTRAL] 4813.
[AGENT][NEUTRAL] So this one, there was an actual um another charge from uh Holy Cross Hospital for a clinic visit for the same day, um, you know, for your facility. That claim, um, that claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Was, uh, again for that same data service of $725 for Holy Cross Hospital, those charges on that claim were $392 and that's where most of the benefit was paid to is that claim and that claim is $351.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] 4813.
[AGENT][NEUTRAL] And again it's for Holy Cross Hospital. It's just a different uh service but the same date.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] But it was a different build amount right? the.
[AGENT][NEUTRAL] That's right, mhm.
[CUSTOMER][NEUTRAL] And do you have the builder amount?
[AGENT][NEUTRAL] 392.
[CUSTOMER][POSITIVE] 392 thank you so much [PII] for that valuable information and um now it makes uh like you know and I just wanna know like uh the remaining balance on this claim uh can we be able to bill this to patients?
[AGENT][NEUTRAL] Well, we don't determine that patient liability, uh, [PII], because this policy is a limited supplemental benefit plan, so, uh, we pay their benefits based on what their policy or their plan allows um we don't determine that patient responsibility though there is no write off, there is no contractual adjustment it's a, it's a benefit payment payable under their supplemental plan.
[CUSTOMER][NEUTRAL] Mm mhm.
[AGENT][NEUTRAL] So, um, the, the balance would be between the patient and the provider and if that's your practice, then that's what you would, um.
[AGENT][NEUTRAL] That's what you would need to do, but we don't tell you what to bill to the patient because again there's no, this is not a major medical, there's no contractual adjustments made.
[CUSTOMER][NEUTRAL] Yes, mhm.
[CUSTOMER][NEUTRAL] OK, so the patient has already met his, uh, day maximum on the date of service. All right, makes sense. Uh, thank you, yeah, thank you so much for [PII] for your valuable information and assistance. And, uh, can I get a call reference for our conversation?
[AGENT][POSITIVE] That's right.
[AGENT][NEUTRAL] Certainly, did you have any other questions, [PII]?
[CUSTOMER][NEUTRAL] Uh, that's all for the day.
[AGENT][NEUTRAL] OK, so the call reference number you would use my name in today's date and my first name [PII]
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Last initial is [PII] and today's date.
[CUSTOMER][POSITIVE] Perfect. Perfect. Thank you so much, [PII] for your available information and assistance and uh you two have a great rest of your day and uh bye for now.
[AGENT][POSITIVE] You too, [PII], thank you so much for calling API. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Thank you. Bye for now.
[AGENT][POSITIVE] Take care bye bye.