AccountId: 011433970860
ContactId: 74342f7a-a315-40a4-9f2a-5a5ae0df093d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 462760 ms
Total Talk Time (AGENT): 207728 ms
Total Talk Time (CUSTOMER): 138398 ms
Interruptions: 1
Overall Sentiment: AGENT=0.9, CUSTOMER=1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/11/74342f7a-a315-40a4-9f2a-5a5ae0df093d_20250411T18:33_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] Hi, [PII]. My name is [PII] and I'm calling with the provider's office in [PII]. I need to check status on the claim.
[AGENT][NEUTRAL] OK, [PII], you have one claim you're needing to check status on, is that correct?
[CUSTOMER][POSITIVE] That's correct.
[AGENT][POSITIVE] Yes, ma'am, I can help you. And what is your callback number, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Thank you. And what is the member's policy number, please, [PII]?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I have 20055. Let me look again here.
[AGENT][NEUTRAL] OK, that's a group number. That's not the policy number.
[CUSTOMER][NEUTRAL] All right, let's see.
[CUSTOMER][NEUTRAL] And I don't have anything else, so can we look by the name? This might be why this isn't paying. Can we look by the name and the date of birth?
[AGENT][NEUTRAL] Give me just a moment please.
[AGENT][NEUTRAL] You said the group number was 20055?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] What is the last?
[CUSTOMER][NEUTRAL] But they haven't listed as the ID.
[AGENT][NEUTRAL] Yes, ma'am, that's, that's incorrect. So I will, once I locate the information, I will provide you the correct information. So, what is the patient's name first off?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, so I believe I've located her policy and any information provided would be a verification of benefits and not a guarantee of payment. What is her date of birth, [PII]?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] So the correct policy number that you should have for this number is 02538053.
[CUSTOMER][NEUTRAL] OK, this is weird because
[CUSTOMER][NEUTRAL] We have you guys, we have you guys listed as the secondary payer to Aetna.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] We would be the secondary.
[CUSTOMER][NEUTRAL] We have a we have a claim on file.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, for [PII] that supposedly somebody called on and spoke to you about the payment that was to have been made on the claim, but I don't see how they would have called if the policy number wasn't right. Do you happen to have any claims on file for [PII]?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] That they could
[AGENT][NEUTRAL] What is the total bill amount for that data service?
[CUSTOMER][NEUTRAL] Um, total bill amount is $6,483.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] And it was [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] OK, so we did receive a claim [PII].
[AGENT][NEUTRAL] And it was processed on [PII].
[AGENT][NEUTRAL] There was, and that was on claim number 3549589.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what, uh, verify that you.
[AGENT][NEUTRAL] Providers, the facility name and address.
[CUSTOMER][NEUTRAL] Um, it's under Key West HMA Physicians Management, uh, Lower Keys Medical Group, uh, [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so that doesn't, what is the tax ID number?
[CUSTOMER][NEUTRAL] It is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK. So that check was issued. It was mailed to a [PII].
[AGENT][NEUTRAL] For that, and that has cleared, that cleared on [PII].
[CUSTOMER][NEUTRAL] OK, and how much was paid?
[AGENT][NEUTRAL] $3000 even.
[CUSTOMER][NEUTRAL] OK, that's my next question. How was more paid than was due?
[CUSTOMER][NEUTRAL] Because Aetna processed on this claim.
[AGENT][NEUTRAL] What we received was there was a charge, OK.
[AGENT][NEUTRAL] So the total bill amount showed is the 6483, then it had a charge of 4810. 97, and the benefit paid $3000. And with that payment, the maximum benefits for that service date was met, I believe, let me, let me get back to this remark. Give me just one second.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Oh, OK, OK, perfect, so that means that.
[AGENT][NEUTRAL] So it's say
[AGENT][NEUTRAL] Yes, so then it showed 4810.97, the benefit paid $3000 and with that payment, it states the calendar, your maximum for this benefit has been exhausted with the payment of this claim.
[CUSTOMER][NEUTRAL] OK, so $3000 was it. So hypothetically, the, the remainder of the balance which is $1810 is patient responsibility.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] We do not determine patient responsibility, that would be up to the provider.
[CUSTOMER][NEUTRAL] No, that's fine because the, the primary.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The primary process to claim, the balance was $4810.97. You guys paid the maximum a lot of $3000 so the balance is patient responsibility. I just want to make sure with you guys that everything I was seeing was correct.
[AGENT][POSITIVE] Mhm. Correct.
[AGENT][POSITIVE] Yes, ma'am. That is correct.
[CUSTOMER][NEUTRAL] OK, is this a sort of a supplemental plan?
[AGENT][NEUTRAL] This, we are not a major medical insurance. This is a supplemental policy that helps them with their co-pays, deductibles and co-insurance amounts of covered services up to their benefit maximums on the plan.
[CUSTOMER][POSITIVE] OK, I got you. You've been very helpful. Can I get a reference number for our call?
[AGENT][NEUTRAL] OK, sure, you would use my name that I gave you [PII] along with today's date and then also I'm gonna go ahead and give you our website for our portal so in the future or if even for this one you need a copy of that explanation of benefits, you should be able to print that with the claim number that I gave you by going to [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Awesome alrighty then I thank you so much for your time you have a great weekend.
[AGENT][POSITIVE] All right. Well, you, I hope you have a great weekend too. So is there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, that's it for today. Thank you again.
[AGENT][POSITIVE] OK. Well, you're very welcome and have a great weekend and thank you for calling APL.
[CUSTOMER][NEUTRAL] Uh huh bye bye.
[AGENT][NEUTRAL] Bye-bye.