AccountId: 011433970860
ContactId: 6ba66dc2-e534-4f03-b3f3-13542b71db1d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 222220 ms
Total Talk Time (AGENT): 86224 ms
Total Talk Time (CUSTOMER): 105881 ms
Interruptions: 0
Overall Sentiment: AGENT=1.1, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/6ba66dc2-e534-4f03-b3f3-13542b71db1d_20250121T16:03_UTC.wav
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[AGENT][NEUTRAL] This is [PII].
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] on the care team. How are you?
[AGENT][POSITIVE] I'm good. How are you?
[CUSTOMER][POSITIVE] I'm doing good. I have a provider on the other line that has a question about um the explanation of benefits that they provided for a claim.
[CUSTOMER][NEUTRAL] Um, I went over the claim status with them and I explained what we were looking for, but she's saying it's a hostile indemnity policy, so they don't have anything that's paid to the deductible or co-pay, and I didn't know where to go from there.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. What's the policy number?
[CUSTOMER][NEUTRAL] Um, it's 217-359-6.
[AGENT][NEUTRAL] OK, and who's the patient?
[CUSTOMER][NEUTRAL] Um, oh, hold on, let me go.
[CUSTOMER][NEUTRAL] It's number one, I forgot the name, [PII].
[AGENT][NEUTRAL] OK. And her name, the caller's name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. All right. You can send her over. We'll figure it out.
[CUSTOMER][NEUTRAL] All right thank you [PII] hold on one moment.
[AGENT][POSITIVE] Mhm. No problem.
[CUSTOMER][POSITIVE] Hello [PII]. Yes, thank you so much for holding. I have Easy on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] Thank you. You're welcome.
[AGENT][NEUTRAL] Hi [PII], this is [PII] in the claims department. Could you please verify the policy number one more time?
[CUSTOMER][NEUTRAL] Yes, um, let me go back.
[CUSTOMER][NEUTRAL] That's gonna be 021-73596.
[AGENT][NEUTRAL] OK, and please verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Um, [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what's the date of service and bill charges for the claim you're calling about?
[CUSTOMER][NEUTRAL] Um, it's gonna be a date range, [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the bill amount is $2,159 even.
[AGENT][NEUTRAL] OK. Yes, ma'am. I'm showing that this claim denied because according to the documentation um that you guys sent along with the claim, and that's all the information we can go by, it's not showing what charges went to the co-pay, the co-insurance, or the deductible. And under this policy, this is a policy for secondary gap insurance.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What we do is cover the co-pay, the co-insurance, and the deductible after the primary insurance processes the claim. And unfortunately, the EOB that was sent along with this claim doesn't show that. Um, if you guys do have an updated EOB that provides that information, the claim can be resubmitted and reprocessed.
[CUSTOMER][NEUTRAL] OK, so it's not applied to the patient. So if it's not applied to the patient, deductible, co-pay or co-insurance, you guys don't cover that, and that's just member responsibility because this patient's primary is like a limited and their max benefits has been max. So the 9034 is not considered co-pay, deductible or co-insurance. It's they're responsible because they have maxed out all their benefits.
[AGENT][POSITIVE] Um, yes, ma'am. Then that, that will be patient responsibility.
[CUSTOMER][NEUTRAL] So I just wanna be able to.
[CUSTOMER][NEUTRAL] OK, alright, [PII] and your name again?
[AGENT][NEUTRAL] It's [PII]. Um, it's spelled [PII] and my last initial is [PII]. Is there anything else that I can assist you with?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you guys give out call reference?
[AGENT][NEUTRAL] You can use my name and today's date for the reference number.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] OK, thank you, [PII] for calling APO. You have a great rest of your day. Mm bye.
[CUSTOMER][NEUTRAL] You too bye bye.