AccountId: 011433970860
ContactId: 7a59da0c-cb06-4315-b8a7-d0c01c812c90
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 813979 ms
Total Talk Time (AGENT): 301951 ms
Total Talk Time (CUSTOMER): 195622 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/24/7a59da0c-cb06-4315-b8a7-d0c01c812c90_20250424T18:08_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi Miss [PII], my name is [PII]. I'm hoping I reached the right department. I'm calling in regards to a claim.
[AGENT][NEUTRAL] OK, did you need claim status or it's a denial you want to talk about?
[CUSTOMER][NEUTRAL] Claim status, yes ma'am.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status, and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII], no extension.
[AGENT][NEUTRAL] Thank you. May I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, that is D as in Delta 435-09210.
[AGENT][NEUTRAL] Alright, and do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] Uh, yes, I do. Let me get back to it one second.
[CUSTOMER][NEUTRAL] OK, what did you need off the card?
[AGENT][NEUTRAL] Um, so it should say in hospital or outpatient policy er number. Um, it may just say policy er number, but it's starting with a 01 or 02.
[CUSTOMER][NEUTRAL] Uh, no, this one just says employee name, employee ID number, which is that the number, um, for medical benefits services contact that contact number 90 degree benefits coverage is subject to plan provisions and limitations, um, and then it has.
[AGENT][NEUTRAL] OK, hold on. The
[AGENT][NEUTRAL] So did you call an 800 number or [PII] number?
[CUSTOMER][NEUTRAL] So the contact number that I called was [PII]. It was supposed to be for multi-plan, which I believe is over the 90 degree benefits from what the car is advising.
[AGENT][NEUTRAL] Alright, hold on one second. So that phone number is the 90 Degree benefits, which is also where that D number is going. Um, so if you call that number, it sounds like you were rerouted to us, but if you want me to check and see, I can still check with the member's first and last name.
[AGENT][NEUTRAL] Just to see if they have anything here with APL if you like.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, are you guys like a partnership with Multi-lan 90 Degrees or are you completely different entity?
[AGENT][NEUTRAL] That's hard to answer. OK, so 90 Degree benefits works with a lot of different insurance companies. So yes, we work with them, but that doesn't mean this policy is ours. It could, it could just be, you know, another insurance company, but there's an option there when you call that [PII] that will redirect it to us because our phone number is [PII], so it's the wrong number altogether. But
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, it, it routed me there then huh.
[AGENT][NEUTRAL] Sounds like you were redirected, yeah, but I can check just to make sure if you'd like.
[CUSTOMER][NEUTRAL] Yeah we can um you needed the patient's name you said?
[AGENT][NEUTRAL] Yes, ma'am, the first and last name.
[CUSTOMER][NEUTRAL] [PII], it's [PII] Last name is [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] I'm just waiting for the policies to come up here. Hold on one moment.
[AGENT][POSITIVE] I'll use this one.
[AGENT][NEUTRAL] Is the middle initial D like dog?
[CUSTOMER][NEUTRAL] Uh yes it is.
[AGENT][NEUTRAL] OK, hold on.
[AGENT][NEUTRAL] There's no active policies with us, but he has had policies with us, so it could be an older claim. Let me get in here. Hold on one moment.
[CUSTOMER][NEUTRAL] So our claim data service OK.
[AGENT][NEUTRAL] Well, hold on. May I have the member's date of birth?
[CUSTOMER][NEUTRAL] Yes, patient's date of birth [PII].
[AGENT][NEUTRAL] OK, here we go. Thank you. And all the information provided is a verification of benefits, not a guarantee of payment. And what is the date of service and the total bills?
[CUSTOMER][NEUTRAL] Data service was on.
[CUSTOMER][NEUTRAL] [PII] and the amount $15,0048.26.
[AGENT][NEUTRAL] OK, [PII]. So which one was active? Hold on one second.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] I believe I just located which policy it was processed and I'm looking for the data service now hold on one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And [PII], do you mind if I place you on just a brief hold?
[CUSTOMER][POSITIVE] Yeah, no problem.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, wait.
[AGENT][NEUTRAL] Multiplan hospitality is nothing else but.
[AGENT][NEUTRAL] So [PII].
[AGENT][NEUTRAL] It has to be that one.
[AGENT][NEUTRAL] Oh, wait a minute. It doesn't have to be that one because look at this. I had.
[AGENT][NEUTRAL] What?
[AGENT][NEUTRAL] October
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Because this one's alright, let me just try. I don't have time for that. 227802825. Is that right?
[AGENT][NEUTRAL] Let's try
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 331-447-6. Where did I get a 9 from?
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] What is this? Oh, it's a HR policy. I'm like, why isn't it working?
[AGENT][NEUTRAL] OK, so let's add it up then calculator.
[AGENT][NEUTRAL] Basically, this is the time.
[AGENT][NEUTRAL] Let me get the reasons.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. So the claim, uh, the policy number that the claim was processed under, um, is 227.
[AGENT][NEUTRAL] 2825.
[AGENT][NEUTRAL] The claim was received on [PII].
[AGENT][NEUTRAL] And that claim number is 331.
[AGENT][NEUTRAL] 4476.
[AGENT][NEUTRAL] And on [PII], the claim was denied?
[AGENT][NEUTRAL] Um, the emergency room was charged, was, I'm sorry, the emergency room was was denied, um, because the benefit maximum for the data service has been met.
[CUSTOMER][NEUTRAL] And I said maximum for data service what's map OK.
[AGENT][NEUTRAL] And then code 74177 was denied because the calendar year max on diagnostic services has been met.
[CUSTOMER][NEUTRAL] OK, give me that one more time code 741777.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Calendar year maximum.
[AGENT][NEUTRAL] On diagnostic services.
[AGENT][NEUTRAL] Has been met.
[CUSTOMER][NEUTRAL] OK, so on that there was no payout at all, is that correct?
[AGENT][POSITIVE] Yes, ma'am, that's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, and then on my side I don't know if they just documented the wrong claim number, but they do have a different claim number. I don't know if it just goes to 90,360 or something, but I'm gonna give you this claim number it's longer than yours 202306020737. Does that sound like anything that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Would pull up in your system as a claim.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, so I'll use your claim number you gave me the 331-447-6 received 7723 and process 715-23. There was no payment made and is everything listed as patient responsibility?
[AGENT][NEUTRAL] So we don't determine patient responsibility because we're not the major medical um or a major medical insurance company, um, so it would just be whatever your outstanding balance or remaining balance procedures are.
[CUSTOMER][NEUTRAL] OK, can you tell me what the patient's effective dates are?
[AGENT][NEUTRAL] Mm, hold on one moment.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Um, this policy was active from [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What type of plan was it?
[AGENT][NEUTRAL] Um, this is a hospital indemnity policy.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Indemn the policy.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] Bear with me just one second, can I place you on a brief hold?
[AGENT][POSITIVE] Of course. Take your time.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alrighty and underneath coordination of benefits, I don't know if you guys coordinate benefits or not, but if so, can you tell me when that was last updated?
[AGENT][NEUTRAL] Um, so for this policy, we don't coordinate benefits. Um,
[CUSTOMER][NEUTRAL] OK, no worries, and then, um, on the claim itself, does it show us as processing in or out of network?
[AGENT][NEUTRAL] Yeah, it's not second to anything.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] So we don't really, OK, so how the hospital indemnity policies work, yeah, it, there's no network for the hospital indemnity. They do have the PPO through multi-plan, but that
[CUSTOMER][NEUTRAL] The network
[AGENT][NEUTRAL] APL wouldn't run that?
[AGENT][NEUTRAL] So it, it goes to IMA? OK, you're welcome.
[CUSTOMER][POSITIVE] OK, no worries, thank you for that.
[CUSTOMER][NEUTRAL] I got it. It's one of those indemnities. They're a little tricky, so I just gotta noted and then what is our reference number today?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][POSITIVE] Excellent thank you for your help today you have a great day.
[AGENT][POSITIVE] You're welcome, [PII]. You