AccountId: 011433970860
ContactId: 75b1bc64-fd52-42a4-a44d-1eb893e3e082
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 403839 ms
Total Talk Time (AGENT): 161801 ms
Total Talk Time (CUSTOMER): 128016 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/75b1bc64-fd52-42a4-a44d-1eb893e3e082_20250103T21:23_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, so, my name's [PII]. I'm calling from Santa Clara Valley Healthcare.
[AGENT][NEUTRAL] Yes, and how may I assist you today, Mr. [PII]?
[CUSTOMER][NEUTRAL] Um, I have one of your members here with me. We're just following up on a claim that we sent and just to, um, verify if he has coverage or not for medical benefits for a data service. Would you be able to assist?
[AGENT][NEUTRAL] OK, yeah, sure, yes, I can assist you with claims for effective date of the policy, and may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure, the callback number here is [PII].
[AGENT][NEUTRAL] OK, thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Uh, we have a member ID number of 241-8205.
[AGENT][NEUTRAL] OK. Thank you. One moment, let me pull that information.
[CUSTOMER][NEUTRAL] And ma'am, what was your first name?
[AGENT][NEUTRAL] My name is [PII] [PII].
[CUSTOMER][NEUTRAL] [PII], is there a reference number for today's call?
[AGENT][NEUTRAL] We don't have numbers. You can use my name in today's name.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and may I have the name and date of birth of the patient, Mr. [PII]?
[CUSTOMER][NEUTRAL] Sure, the patient's name I'm gonna mispronounce it [PII].
[CUSTOMER][NEUTRAL] Many [PII], I can spell it out for you if you want and the date of birth is [PII].
[AGENT][NEUTRAL] No, it's fine.
[AGENT][NEUTRAL] OK, thank you. All right, let's see.
[AGENT][NEUTRAL] OK, so it looks like this policy was effective from [PII] and it terminated on [PII].
[CUSTOMER][NEUTRAL] OK, and this is for medical benefits?
[AGENT][NEUTRAL] This is a limited plan, um, what type of service was rendered?
[CUSTOMER][NEUTRAL] Um, it's an inpatient admission for 2 days.
[AGENT][NEUTRAL] Miss.
[AGENT][NEUTRAL] OK. Yeah, this one is a hospital indemnity plan.
[CUSTOMER][NEUTRAL] OK, so there is coverage available?
[AGENT][NEUTRAL] Um, let me check the benefits really quick. One moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] It's gonna be a minute because it's terminated. It will not let me go about um this other way, so I'll have to look for the certificate. OK, one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then I'm also gonna ask about the claim that we sent on [PII] for this account.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That was number 14 of this year of last year, not this year, but last year.
[CUSTOMER][NEUTRAL] Yeah, yeah, [PII], a claim was submitted via paper.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That's the day it was submit or that's the day of service?
[CUSTOMER][NEUTRAL] That's the day it was submitted [PII].
[AGENT][NEUTRAL] What's the date of service?
[CUSTOMER][NEUTRAL] Data services [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] And how much is the total charge?
[CUSTOMER][NEUTRAL] The total charge was $34,730.87.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, here's the certificate.
[AGENT][NEUTRAL] OK, so this is not a guarantee of payment, just a verification of coverage. It looks like this particular policy had a um one time per year admission benefit of $500.
[AGENT][NEUTRAL] And then a
[CUSTOMER][NEUTRAL] I'm sorry, so that means the patient has a liability of 500 or you cover 500?
[AGENT][NEUTRAL] We, we cover 500 for the admission, and that's 1 day per year.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then the hospital confinement benefit is $100 per day.
[AGENT][NEUTRAL] Up to 10 days.
[AGENT][NEUTRAL] Per year.
[CUSTOMER][NEUTRAL] And so, so that's just his coverage.
[AGENT][NEUTRAL] Yes, that is covered. Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it looks like the mhm go ahead.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK, now I'm just trying to figure out what the patient's liability is gonna be if it's.
[CUSTOMER][NEUTRAL] But we will wait
[AGENT][NEUTRAL] Well, um,
[AGENT][NEUTRAL] Yeah, we're not a major medical, so we don't really apply anything towards the deductible co-payment or co-insurance or members responsibility. Um, this is a limited hospital indemnity plan which it pays an indemnity, um, flat amount.
[AGENT][NEUTRAL] Um, it looks like based on that information we did send the $500 and the $100 for the confinement of [PII].
[AGENT][NEUTRAL] To the provider?
[AGENT][NEUTRAL] And that is the maximum that the policy will pay.
[CUSTOMER][NEUTRAL] OK, so for the $34,000 claim, uh, your insurance is covering $600?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, alright, I will, um, but this is not a verification so I will let the patient know of that outcome and we will wait for payment and uh to determine the patient's liability or how much they owe.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, so you have not received the, the check of 600 yet?
[CUSTOMER][NEUTRAL] Uh, it has not been posted yet.
[AGENT][NEUTRAL] Oh, OK, got you. OK.
[CUSTOMER][POSITIVE] All right great thank you so much.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] You're welcome. Is there anything else I may help you with today, Mr. [PII]?
[CUSTOMER][POSITIVE] No, no, thank you so it's been a pleasure bye bye.
[AGENT][POSITIVE] You're welcome and thank you for calling ATL. Have a good afternoon.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Mm