AccountId: 011433970860
ContactId: 672d26b6-47a1-4719-a089-537fa5483026
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 302769 ms
Total Talk Time (AGENT): 104508 ms
Total Talk Time (CUSTOMER): 147279 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/672d26b6-47a1-4719-a089-537fa5483026_20250114T13:02_UTC.wav
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[AGENT][NEUTRAL] APL this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, hi, I have a question um with my son's claim.
[AGENT][NEUTRAL] OK, are you on the policy? Are you the policy holder?
[CUSTOMER][NEUTRAL] Yes, I'm on the policy.
[AGENT][NEUTRAL] And your name?
[CUSTOMER][NEUTRAL] Last name is [PII]. First name is [PII].
[AGENT][NEUTRAL] And what's the policy number?
[CUSTOMER][NEUTRAL] The policy number is 01070980.
[AGENT][POSITIVE] And a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And what's your uh date of birth and your mailing address?
[CUSTOMER][NEUTRAL] My date of birth is [PII]. The mailing address is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. One moment.
[AGENT][NEUTRAL] And which dependent son?
[CUSTOMER][NEUTRAL] Uh, it's [PII].
[AGENT][NEUTRAL] OK. What's [PII]'s date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and do you have the date of service of the claim that you're calling on?
[CUSTOMER][NEUTRAL] Yes, it's [PII] last year, [PII].
[AGENT][NEUTRAL] And who is the provider, do you know?
[CUSTOMER][NEUTRAL] Uh, yes, it's Baptist Health.
[AGENT][NEUTRAL] That is OK. Let me pull up the history and then I'll be able to search that for you.
[AGENT][NEUTRAL] Is it, is it Baptist Health Medical Group and office visit fee or is it in hospital service?
[CUSTOMER][NEUTRAL] No, it's medical group.
[AGENT][NEUTRAL] OK, an office visit. OK, so I'm showing that a $25 payment was made, um, on that date of service. Uh, looks like this was processed on [PII].
[CUSTOMER][NEUTRAL] Right, because what happened is, I don't know why they, they told me they send it back to you guys to still see because the co-pay is supposed to be $40. So they said they're still pending to, they send you a notice to see if they can get the other 15. Does it show in the system they did that or no?
[AGENT][NEUTRAL] Well, under this policy, the maximum benefit per data service is 25.
[CUSTOMER][NEUTRAL] No, I know, I know that too, but for some reason, they said, they're still pending, they tried to resubmit it to you guys, but the other 15.
[AGENT][NEUTRAL] Why are they resubmitting it?
[CUSTOMER][NEUTRAL] I don't know, it's kind of weird, but that's what they told me they were doing. It's pending.
[CUSTOMER][NEUTRAL] It's pending to hear from you guys. Did you receive anything about the $15?
[AGENT][NEGATIVE] You know, this is the only one that we've received and on the claim that we processed on the explanation of benefits, it specifically states that um the $25 exhausted the benefit for this state of service, which means there's no more benefits payable.
[CUSTOMER][NEUTRAL] Right, yes, I know, cause I got, I got a copy on that too, so you didn't get another.
[AGENT][NEUTRAL] OK. No.
[CUSTOMER][NEUTRAL] Right, OK, but for some reason it's still pending, so they did not resubmit something else for the $15.
[AGENT][NEUTRAL] They, they didn't send another claim.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] So that's, that's an out of pocket expense for the, the policyholder, the $15.
[CUSTOMER][NEUTRAL] No, I know, I know, I know, but for some reason they, no, I'm aware, I'm completely aware of it, but I just wonder why.
[AGENT][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But they told me that they, they, they, it's fine, it's still pending with them, but the, the reason is pending over at Baptist Health is they said, oh, we resubmitted it to APL again to see if we can get the $15 which I don't understand why they would do that. Did you receive it on your end?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] We did not.
[CUSTOMER][NEGATIVE] You did not receive the resubmission.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, I guess maybe it's the system that they just have to go through the system and process it then. OK, all right, thank you.
[AGENT][NEGATIVE] So they're they're sending it so that we can deny it again as benefit exhausted.
[CUSTOMER][NEUTRAL] I think that's what they're doing. I don't know if, I know what you mean, cause I, I do this all the time that I'm the type that I like to stay on top of my bills. I wish they would just send me the, the balance of $15 to get it over with, but for some reason, they said, no, it's pending, we resubmitting it, or, or some, that's what they said, we'll resubmitting it to see if we can get the $15 which you're gonna deny it anyway because it's only $25 per visit.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, exactly. OK. So at this.
[CUSTOMER][NEGATIVE] Oh, but you did not receive the resubmission.
[AGENT][NEUTRAL] Yeah, at this time I do not show another day another claim for that data service.
[CUSTOMER][POSITIVE] OK. All right, thanks for checking. I appreciate it. Have a great day.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] All right, [PII], I have no other questions. Thanks for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye bye.