AccountId: 011433970860
ContactId: 6dd00e7f-3d65-4430-9dd4-eef939e59dc4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1331979 ms
Total Talk Time (AGENT): 496110 ms
Total Talk Time (CUSTOMER): 459593 ms
Interruptions: 8
Overall Sentiment: AGENT=0.3, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/02/6dd00e7f-3d65-4430-9dd4-eef939e59dc4_20250102T17:56_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh hi, [PII]. My name is [PII] calling you from Mercy Hospital. I'm calling you know information on my claim.
[AGENT][NEUTRAL] OK, so this is a claim that's already been processed and you have information on that you're needing additional information?
[CUSTOMER][NEUTRAL] Um, yes, I just in the general claim status.
[AGENT][NEUTRAL] OK. Yes, sir, I can help you with that. Could you please spell your name for me?
[CUSTOMER][NEUTRAL] Uh definitely. My name is [PII]. That's spelled [PII].
[AGENT][NEUTRAL] So [PII], is that correct?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] Oh, OK. And then the first initial to last name is [PII]?
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK, thank you. And what is your callback number, please, [PII]?
[CUSTOMER][NEUTRAL] Yes. Our callback number [PII].
[AGENT][NEUTRAL] OK, and the area code was [PII]. Is that correct?
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK, thank you. And what is, uh, so I can help you with this additional information that you're needing. What is the member's policy number?
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yes, that policy number under 02387858.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And any information that I do provide will be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, their name is [PII].
[CUSTOMER][NEUTRAL] Yeah. Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Day of service and total bill amount, please?
[CUSTOMER][NEUTRAL] [PII] and that amount bill was $3,559 even.
[AGENT][NEUTRAL] And the claim number.
[CUSTOMER][NEUTRAL] One moment, so.
[CUSTOMER][NEUTRAL] The claim number we received was 348-08778.
[AGENT][NEUTRAL] OK, so let me look to see, um, on this policy.
[AGENT][NEUTRAL] One moment. On this policy, there is no claim for that date of service because this policy number you gave me had turned 128-2024.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So let me see if there's another policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And there was. So the correct policy number that you should have for the data service in question is 0247.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 3784.
[AGENT][NEUTRAL] And give me a moment to pull.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that policy was active from [PII] to [PII]. It is also terms.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. So, I do have that claim. And how can I help you with that?
[AGENT][NEUTRAL] You're needing to know the denial reason?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] Yeah, you know, we got to know the reason on when, yeah, on [PII], 1 of our colleagues called and she got to know that uh the claim was denied as members, you know, um, yeah, it is denied for.
[CUSTOMER][NEUTRAL] Benefit maximum met under the patient plan.
[AGENT][NEGATIVE] The exact remark reads benefit maximum for this date of service has been met. That is the specific denial.
[CUSTOMER][NEUTRAL] Yeah, and we also have.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, for this state of service has been met, yes. OK, whatever. Uh, we also have uh we also have requested and you'll be on the same day, but we haven't received it yet.
[AGENT][NEUTRAL] OK, so you can print the EOB yourself if it was requested, you can print that from our portal directly.
[AGENT][NEUTRAL] By going to secured.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, can you please guide me? I'm just, I'm just opening the website.
[AGENT][NEUTRAL] The website
[CUSTOMER][NEUTRAL] I need your help. You said, yeah.
[AGENT][POSITIVE] Secured
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And popular.
[CUSTOMER][NEUTRAL] OK and [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One moment please. Yeah, it's asking me for a login for credentials like I, I did, yeah.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] That is correct. You would have to do, you would have to set up your, uh huh, you would select new user.
[AGENT][NEUTRAL] And you will answer, you will just walk through the steps answering the questions.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And filling in the requested information.
[CUSTOMER][NEUTRAL] I'm sorry, what was that?
[CUSTOMER][NEUTRAL] What should this election here, it's saying like, you know which which best describes you.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And you're calling from a provider. Mhm. Correct.
[CUSTOMER][NEUTRAL] OK, I'm a medical card. Yes, correct, medical provider, yeah.
[AGENT][NEUTRAL] Mhm. So you would select that and click next.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yes, the tax ID, right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, hang on, let me just.
[AGENT][NEUTRAL] You'll need to enter that information. Mhm.
[CUSTOMER][NEUTRAL] Yeah, I'm just putting it in here. OK, [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, not taken.
[CUSTOMER][NEUTRAL] No, [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Patient account number.
[AGENT][NEUTRAL] And that is the account number that the provider, it's not their APO policy number.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] A lot of people get confused on that, but it's the
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] That number that starts with an H. Mhm.
[CUSTOMER][POSITIVE] Good. OK.
[CUSTOMER][NEGATIVE] Yes. Oh, it says no user found the information that was entered. Um, if, if this error persists, please contact customer service.
[AGENT][NEUTRAL] What's the
[AGENT][NEUTRAL] What's the tax ID number that you used?
[CUSTOMER][NEUTRAL] Yes, I used the tax ID number.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and then the patient account number?
[CUSTOMER][NEUTRAL] Yes, patient account number 912.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, so on ours, there's an H, the letter H as in hotel before the 9.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] And then at the end, after the number 8, it's 00.
[CUSTOMER][NEUTRAL] 20s, right? Yeah, yeah, yeah.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, OK, let me just get it in here.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] here we go.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][POSITIVE] I hope you'll come up.
[CUSTOMER][NEUTRAL] Yes, OK, create your account.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] create myself.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah that's for.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEUTRAL] Ok let me
[CUSTOMER][NEUTRAL] It's my primary.
[CUSTOMER][POSITIVE] OK, your account has been successfully created.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I need to log in here, yes.
[AGENT][NEUTRAL] And if we have that, you know, if we've processed the claim, uh, for the member, you should be able to pull explanation of benefits from the Shiva.
[CUSTOMER][NEUTRAL] Oh, OK, OK, one moment.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] A bill claim number.
[CUSTOMER][NEUTRAL] Is there any disturbance when I'm talking?
[AGENT][NEUTRAL] [PII], were you speaking to me?
[CUSTOMER][NEUTRAL] Yeah, are you getting any disturbance while I'm talking?
[AGENT][NEUTRAL] Um, am I getting what?
[CUSTOMER][NEUTRAL] Any disturbance like uh any echo or something like that. Yeah.
[AGENT][NEUTRAL] Yes, I am.
[AGENT][NEUTRAL] Yes, it, it's, it's clicking. It sounds like Morse code. It's a clicking sound on my end.
[AGENT][NEUTRAL] That wasn't there when we first got on our call, but it is now.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, yes, that is why I don't know why.
[CUSTOMER][NEUTRAL] Um, I'm sorry, let me go put it.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Sorry
[CUSTOMER][NEUTRAL] Oh, it says 0 claims found. I gave that APL claim number and I gave that patient's first name. OK, let me just get it in here.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Yeah, I think it will come up now.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Oh yes. Got you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Getting your file.
[CUSTOMER][NEUTRAL] Come on.
[CUSTOMER][NEUTRAL] Yeah, it's start in that.
[AGENT][POSITIVE] It is. OK, wonderful.
[CUSTOMER][NEUTRAL] Yes, yes. Go down. Thank you. Let me open this one and I have to see that oh benefit might not this state of service the mat.
[AGENT][NEUTRAL] OK, well,
[AGENT][NEUTRAL] Uh
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. OK. I have a question for you in here. So you said the benefits are, no, they raise the maximum benefits for the day, right? Ser date. So what are the services like, you know,
[AGENT][NEUTRAL] OK, this insurance, this is not major medical insurance. This is a limited benefit plan a hospital indemnity limited benefit plan.
[CUSTOMER][POSITIVE] Yes, please go ahead.
[AGENT][NEUTRAL] So the max benefit limited benefit plan.
[CUSTOMER][NEUTRAL] Uh, limited what?
[AGENT][NEUTRAL] It is not major medical insurance.
[CUSTOMER][NEUTRAL] So what are exhausted in here? Visits, units, or what?
[AGENT][NEUTRAL] This is a dollar amount per calendar for uh let me go back to the claim I got out of that screen. Give me just a second.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] This is for this date of service. So, on this date of service of [PII], the maximum benefit paid was $50.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's the maximum.
[AGENT][NEUTRAL] Emergency room benefit per day.
[AGENT][NEUTRAL] And a maximum of.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] 2 days per calendar so it was just there were other claims processed prior to this one being received that that benefit was paid to.
[CUSTOMER][NEUTRAL] OK, let me check if you have billed any other claim the same date of service like on [PII] or [PII].
[CUSTOMER][NEUTRAL] No, I don't think any other claim was paid, you know, paid or paid on the same day for this.
[AGENT][NEUTRAL] Not maybe not, um, it was, but not to your provider. I can't provide another provider's information, claims information to you.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] OK, no problem, and I do that here. What's the call reference number?
[AGENT][NEUTRAL] Sure, you would use my name that I gave you along with today's date.
[CUSTOMER][POSITIVE] OK, [PII]. Thank you so very much. That's all for now. Have a nice day. Bye-bye.
[AGENT][POSITIVE] Absolutely. Well, OK, well, you're very welcome, [PII].
[CUSTOMER][NEUTRAL] 00, hang on, hang on. I have one more payment here.
[CUSTOMER][POSITIVE] Oh, it's great to have one more claim here. I'm so sorry.
[AGENT][NEUTRAL] For the same patient?
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] And no, it's for a different, yeah, a different patient.
[AGENT][NEUTRAL] OK, so let me finish my portion of what I have to do on this claim before we can move to the next one.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Sure. Take your time.
[AGENT][NEUTRAL] On the claim that we just checked in regards to that $50 per day for an emergency room.
[AGENT][NEUTRAL] Uh, benefit, and that's a 2 day maximum per calendar yea[PII] as well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and what is the next?
[AGENT][NEUTRAL] Members's policy number?
[CUSTOMER][NEUTRAL] 02346520.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And any information provided will be a verification of benefits and not a guarantee of payment and same as the other one, my name in today's date will be your call reference number.
[AGENT][NEUTRAL] And what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh yeah. Their name is uh [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Of what year?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And data service and total build amount.
[CUSTOMER][NEUTRAL] Date of service, um, I was [PII]. And the bill amount at $10,919.65.
[AGENT][NEUTRAL] OK, I'm sorry, that clicking sound is, OK, did you say [PII]?
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] OK, and the amount was 10,919.65, is that correct?
[CUSTOMER][POSITIVE] 65. Perfect. Yes.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So I do see that there was a claim received for her. Uh, the
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim is
[AGENT][NEUTRAL] It was processed and denied on [PII].
[AGENT][NEUTRAL] The claim number is 353-8010.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] This claim was denied and the remark reads as follows. This policy does not provide any benefits.
[AGENT][NEUTRAL] For expenses.
[AGENT][NEUTRAL] Incurred.
[AGENT][NEUTRAL] For the pregnancy?
[AGENT][NEUTRAL] Of a dependent child.
[AGENT][NEUTRAL] Do you need for me to repeat that again, [PII]?
[CUSTOMER][NEUTRAL] Uh, you said, um, this claim is denied, uh, for this policy doesn't provide any benefits, um, for expenses incurred.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For the pregnancy of a dependent child, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, perfect. Yes, sir. That is correct.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Yes, and you know what, we've received an EOP that states the claim is that duplicate.
[CUSTOMER][NEUTRAL] And uh we have resubmitted it on [PII].
[AGENT][NEUTRAL] Hello. OK.
[AGENT][NEGATIVE] I'm sorry, your voice had cut out. I, I can't.
[CUSTOMER][NEUTRAL] Oh, can you hear me OK?
[CUSTOMER][NEUTRAL] OK, uh, can you hear me OK?
[AGENT][NEUTRAL] Uh, I can. Uh, well, not OK, but I can hear you somewhat.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, I'm so sorry. So what I was saying, um, you know, we received a new bill that states the claim is denied as duplicate.
[AGENT][NEUTRAL] Uh-huh. We've received this claim several times.
[AGENT][NEGATIVE] So the most, the one prior to this most recently received and was denied as a duplicate.
[CUSTOMER][NEUTRAL] OK, when was the denied claim? I mean, when was the duplicate claim was received?
[AGENT][NEUTRAL] Like I said, this claim has been received. There's multiple denials for duplicates. OK. The original do you want the original, the original claim received? Do you want that date or do you want all of the duplicate dates?
[CUSTOMER][NEUTRAL] The recent one.
[CUSTOMER][NEUTRAL] OK. So, OK, OK, uh, [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I just need the original received date and the original uh denial reason. Is this the original denial reason that is, you know, the benefits, um, you know, they won't provide for uh pregnancy of the dependent child? Is this the original denial?
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] The original denial was because we needed the primary insurance company's explanation of benefits.
[CUSTOMER][NEUTRAL] OK, that was, uh, you know.
[AGENT][NEUTRAL] We received the claim in April. Uh-huh.
[CUSTOMER][POSITIVE] Yeah, we have submitted the primary you will be right.
[AGENT][NEGATIVE] And then it got we didn't receive that we continued to receive only the claims again which got denied as duplicates.
[AGENT][NEUTRAL] We didn't receive the EOB until the claim number that I gave you today that was processed with a remark on it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEGATIVE] Regarding no benefits for dependent.
[CUSTOMER][NEUTRAL] OK. Got you, got you. So we need to bill it to the member, the total bill amount?
[AGENT][NEUTRAL] Children.
[AGENT][NEUTRAL] We, this is a supplemental policy, so because we do not determine patient responsibility, that would be up to the provider to determine that.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, uh, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I need to check these numbers or the visits if any claim got paid.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, 4:14.
[CUSTOMER][POSITIVE] Yeah, I'm sorry.
[CUSTOMER][NEUTRAL] Oh I want that.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK, no problem, um.
[CUSTOMER][NEUTRAL] Now what is that call reference number? Call reference number is your name, right?
[AGENT][POSITIVE] Uh-huh, that is correct.
[CUSTOMER][POSITIVE] Yeah, OK, Ms. [PII], thank you. That's all for now. Bye-bye. Have a nice day. [PII].
[AGENT][POSITIVE] OK. Well, oh, well, I hope you, [PII] to you as well, [PII], and thank you again for calling APL. Have a great afternoon.
[CUSTOMER][POSITIVE] Yeah, thanks, bye bye.
[AGENT][POSITIVE] Thank you.