AccountId: 011433970860
ContactId: 627859df-3823-40a6-bd0c-1184d9db5166
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 592179 ms
Total Talk Time (AGENT): 300313 ms
Total Talk Time (CUSTOMER): 201055 ms
Interruptions: 3
Overall Sentiment: AGENT=0.7, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/17/627859df-3823-40a6-bd0c-1184d9db5166_20250217T21:04_UTC.wav
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[AGENT][POSITIVE] Good. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII] in [PII]. How you doing?
[AGENT][NEUTRAL] Hey, [PII]. How are you?
[CUSTOMER][POSITIVE] Doing great, doing great, trying to, I'm trying to see if you don't mind. I got a guy who's clean, um, it was pretty clean, but I, I, I got a message on an EOB that I've never seen before. Um, would you mind if I gave you a policy number?
[AGENT][POSITIVE] Good, good.
[AGENT][NEUTRAL] Sure [PII], uh, go ahead and give me your call back number please.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Thank you and the member's policy number please?
[CUSTOMER][NEUTRAL] Should be 257-2252.
[AGENT][NEUTRAL] OK, thank you. So you have a question on a claim on the remark on the EOB that you got, is that right?
[CUSTOMER][NEUTRAL] Well, yes, ma'am, yes ma'am. Uh, the, the gentleman's name is [PII]. He had a hospital claim and he sent in the normal paperwork we do for a hospital claim, but they put something on there about not having an assignment of benefits, but we're not assigning any benefits. This is just a claim he filed that's supposed to go to him.
[AGENT][NEUTRAL] OK, so yes, I can take a look at that for you. And uh would you verify his date of birth for me, please?
[CUSTOMER][NEUTRAL] Yes ma'am, [PII].
[AGENT][POSITIVE] Thank you, and then your email.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And [PII], as you know, any information that I provide for you would be a verification of benefits and not a guarantee of payment. Uh, what is the data service and total bill amount?
[AGENT][NEUTRAL] On this claim.
[CUSTOMER][NEUTRAL] Mm let me see if I have any of that here because.
[CUSTOMER][NEUTRAL] What happened was he ported his coverage and then I can't see it in my system anymore. It looks like data service, I believe it's [PII].
[AGENT][NEUTRAL] OK. Do you have a build amount for that data service?
[CUSTOMER][NEGATIVE] It's got a bunch of charges and it's a big bill. It should be the only claim on file for him.
[AGENT][NEUTRAL] Uh, we have more than one claim.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Let's see, it, I can tell you it's a hospital claim.
[AGENT][NEUTRAL] So we have a
[AGENT][NEUTRAL] Mhm. OK. So it's like, we have one for
[AGENT][NEUTRAL] Give me, give me just one second.
[CUSTOMER][NEUTRAL] Sure, and I'm gonna um see if there's a claim number on here too.
[AGENT][NEUTRAL] You do have the claim number?
[CUSTOMER][NEUTRAL] Oh, it ends in 562.
[AGENT][NEUTRAL] OK. So yes, on that claim, I can see that there has been a benefit paid to him.
[CUSTOMER][NEUTRAL] It ends in 562.
[AGENT][NEUTRAL] And the amount of $1100 on this claim, um.
[AGENT][NEUTRAL] OK, with the $1000 state with that benefit paid, it states the calendar year max for this benefit has been exhausted with the payment of this claim.
[CUSTOMER][POSITIVE] OK, OK, we, the Home Office sent us sent us an EOB that was kind of funny, the one I was telling you about.
[AGENT][NEUTRAL] Um, that's one of them.
[AGENT][NEUTRAL] Let me look at the other remarks. One of the code, the, the hospital confinement benefit that was denied because it's not payable, um, let's see, the remark rates, the hospital confinement benefit is not payable on any day a hospital admission benefit is paid.
[AGENT][NEUTRAL] Duplication of benefits is not allowed under the policy and any attached riders if a cover charges payable under, hold on, I'm sorry, my remark is cut off here is payable under more than one benefit only one benefit, the highest will be payable.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Then there was another um
[AGENT][NEUTRAL] There was another benefit. There was a $100 benefit paid on one of the codes, and that states that also the calendar year max for this benefit has been exhausted with the payment of this claim.
[AGENT][NEUTRAL] And that last remark, we have no assignment of benefits on file for this data service.
[AGENT][NEGATIVE] Therefore, we're unable to send information regarding this charge to the provider of service. OK, that is.
[CUSTOMER][NEUTRAL] That's the one they sent me.
[AGENT][NEUTRAL] OK, because this, OK.
[AGENT][NEUTRAL] It looks like the provider also submitted the same $16,000 charge as the insured.
[AGENT][NEUTRAL] So the benefits were paid to the insured and not to the facility.
[CUSTOMER][POSITIVE] Correct, correct, that's how it's supposed to be.
[AGENT][NEUTRAL] Right, and that's what that remark has to do with.
[CUSTOMER][NEUTRAL] OK, so we paid him with.
[AGENT][NEUTRAL] We have no assignment of benefits on file. Therefore, we are unable to send information regarding this charge to the provider of service. Our claim decision is being sent directly to our insured.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that was the hospital admission benefit.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so I'm looking at this bill right here. So, so we paid the surgery benefit of $1000 correct? Or, or was that the surgery benefit or the admission benefit?
[AGENT][NEUTRAL] The hospital admission.
[AGENT][NEUTRAL] That's the admission benefit. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it, got it. I'm so used to 99% of my groups have 1500 admissions, but this group chose 1000. That's what threw me off. OK, um, OK, I was like, wait a minute.
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Uh it's hard to keep up with all of them, I'm sure.
[CUSTOMER][NEUTRAL] Uh yes ma'am. OK, so you got $1000 for the admission and the $100 was for.
[CUSTOMER][NEUTRAL] I guess the extra day in the hospital and then a separate 100 was probably for the ER visit is what I'm thinking.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Give me just a second.
[CUSTOMER][NEUTRAL] Or possibly one of these scans.
[AGENT][NEUTRAL] It was a scan, it looks like.
[CUSTOMER][NEUTRAL] I'm not sure.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like it was the imaging. Um, give me just a second though.
[AGENT][NEUTRAL] Yes, that was the, the 100 was on the major diagnostic exam benefit.
[CUSTOMER][NEUTRAL] Got it, got it, got it. So 1100 and 100, those and those should be I believe uh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Well, 1100, a total of 1100.
[CUSTOMER][NEUTRAL] OK, OK, I'm sorry, I thought it was 1100 then 100. OK, so a total of.
[AGENT][NEUTRAL] No, I'm sorry. I think I said it all together and then broke it down. No, it's a total of 1100.
[CUSTOMER][POSITIVE] Perfect, that's perfect um and do you show that was, um, direct deposit?
[AGENT][NEUTRAL] No. This is was issued via check.
[CUSTOMER][NEUTRAL] And we sent in claims all their direct deposit um weeks ago.
[CUSTOMER][NEUTRAL] I wonder what's going on with that now.
[AGENT][NEUTRAL] I don't know. I can see.
[AGENT][NEUTRAL] Uh, hold on just a second. I need to refresh one of my screens, [PII]. I'm sorry.
[CUSTOMER][NEUTRAL] It's OK.
[AGENT][NEUTRAL] So I don't see.
[CUSTOMER][NEUTRAL] These particular people are.
[AGENT][NEUTRAL] Yeah, I don't
[AGENT][NEUTRAL] It doesn't have direct deposit information. It only has their draft information on file.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I'm going to uh I'll resend that to claims. I'll resend my original email to claims and I will um just let them know that they're supposed to be direct depositing these claims.
[AGENT][NEUTRAL] OK, yeah, if you could do and you just if you'll send that to [PII].
[CUSTOMER][NEUTRAL] So I will work on that on my side.
[CUSTOMER][POSITIVE] Yep, we got it.
[CUSTOMER][POSITIVE] I will take care of it.
[AGENT][NEUTRAL] But yes, so this one this processed on the [PII], so that means the check wouldn't have gone out until.
[AGENT][NEUTRAL] Uh, Friday, probably. I mean, it wouldn't have gone out until at least this past [PII].
[CUSTOMER][NEUTRAL] OK, and I, I think his wife had a had an accident check 450 that went out. It's probably close to the same time, but I assume that was a paper check too.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] On a different policy.
[CUSTOMER][NEUTRAL] Yes ma'am, on their accident plan.
[AGENT][NEUTRAL] OK, I'll have to look at that. I can't, I'm gonna have to pull that information up.
[AGENT][NEUTRAL] I can't see that on
[CUSTOMER][NEUTRAL] That's OK, that's OK.
[AGENT][NEUTRAL] Are you sure?
[CUSTOMER][NEUTRAL] [PII], uh, [PII] already got a, yeah, [PII] got an EOB on it. Um, I was just thinking now that you said that I was like, man, that we, we told our direct deposit, but that's probably a paper check that went out too because they would have.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Yeah, it looks like it. I don't see. Mhm. I don't, uh.
[CUSTOMER][NEUTRAL] Let me see, do frame direct deposit.
[AGENT][NEUTRAL] Yeah, it was. It was a check.
[CUSTOMER][NEUTRAL] OK, no problem, I'm gonna, um, I'm gonna work on that.
[AGENT][NEUTRAL] Yep, so just when you send in your email, [PII], would you um make sure to let include in your email to have that information added on all what whichever policies it needs to be on.
[CUSTOMER][POSITIVE] OK, you got it.
[AGENT][NEUTRAL] For these people, because if you just reference one, you know, there's a possibility that it could just get added, not intentionally for anything to get dropped, but you know if there's only one policy that's referenced, then that could be the only one it gets put on. So if they wanted it on all of them just include that information.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] You got it. I'll take care of it. Thank you for your time today.
[AGENT][POSITIVE] OK. Well, you are welcome. Is there anything else I can help you with?
[CUSTOMER][POSITIVE] That's it. Have a great day.
[AGENT][POSITIVE] You too, [PII], and thank you again for calling APL.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[AGENT][POSITIVE] You're welcome. Bye bye.