AccountId: 011433970860
ContactId: 7e05a8c4-3f6e-42b3-b0fc-d406d91c27dd
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 467480 ms
Total Talk Time (AGENT): 130477 ms
Total Talk Time (CUSTOMER): 186047 ms
Interruptions: 0
Overall Sentiment: AGENT=0.1, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/7e05a8c4-3f6e-42b3-b0fc-d406d91c27dd_20250207T20:41_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. Um, I'm calling from Aperture Consulting. Um, I have a former member on the phone with me named [PII]. Um, I'm her current insurance agent. I was not the agent at the time of her claim, but we're trying to do a little bit of research about a past claim to see how it was, uh, covered if it was ever submitted to her gap plan. I was wondering if with her authorization if we could all speak together about that.
[AGENT][NEUTRAL] Of course.
[CUSTOMER][POSITIVE] Great.
[AGENT][NEUTRAL] OK, hi, if you can just please verify for me, uh, do you have your policy number first off?
[CUSTOMER][NEUTRAL] I do not. I'm sorry.
[AGENT][NEUTRAL] OK, what's your social?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Now what is gonna be the date of service for the claiming question?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you for that.
[AGENT][NEUTRAL] And Miss [PII], if you can verify your date of birth and the email address we had.
[CUSTOMER][NEUTRAL] [PII] and email should be [PII].
[AGENT][NEUTRAL] I'm sorry, did you say [PII] or [PII]?
[CUSTOMER][NEUTRAL] Well
[AGENT][NEUTRAL] For the, for the date of service, I'm sorry, for the date of service, the [PII] or the [PII]?
[CUSTOMER][NEUTRAL] My social?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] The [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] So we received 2 claims for that data service.
[AGENT][NEUTRAL] Who is the provider?
[CUSTOMER][NEUTRAL] Um, I believe it'll be listed as, uh, looks like [PII]
[AGENT][NEUTRAL] OK, so we got one from Geyser, no, not Geyer, Geisinger clinic, and then the other one.
[CUSTOMER][NEUTRAL] It was for
[CUSTOMER][POSITIVE] Geisinger, yeah, that would be right.
[AGENT][NEUTRAL] From the same place, Geisinger Clinic.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's right. It was for an MRI there.
[AGENT][NEUTRAL] So what, what claim?
[AGENT][NEUTRAL] I mean, is there a claim amount um.
[CUSTOMER][NEUTRAL] Well, yeah, so I mean the, the total charge, um, the total charge that was submitted to a primary plan was $5,756. Um, well, actually I'm sorry, there are two claims here. So one was for $5,756 and the other was for $166.17.
[AGENT][NEUTRAL] OK, let me see what these charge amounts were.
[AGENT][NEUTRAL] OK, so the one.
[AGENT][NEUTRAL] For charge amount 5000.
[AGENT][NEUTRAL] $756.
[AGENT][NEUTRAL] We made the payment of $142.60.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mm. I'm sorry, can you give me that figure one more time?
[AGENT][NEUTRAL] We pay $14260142.60.
[CUSTOMER][NEUTRAL] OK, and then the, the second one was that, was that the claim for $166.17?
[AGENT][NEUTRAL] And the 2nd 11 moment.
[AGENT][NEUTRAL] Yeah, 166 17 and that's the one we've made the payment of $89.73.
[CUSTOMER][NEUTRAL] 9
[CUSTOMER][NEUTRAL] OK, and that's the 2:32 and I do see.
[CUSTOMER][NEUTRAL] [PII] applying that payment on there, OK, um.
[CUSTOMER][NEUTRAL] Can you help? I'm, I'm.
[CUSTOMER][NEUTRAL] I'm not very familiar with how this gap plan was to work. Can you help me understand how the, for the MRI how the payment of 14,260 is calculated?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, so let me look at her.
[AGENT][NEUTRAL] OK, so she has a per occurrence benefit of $500.
[AGENT][NEUTRAL] So that iner occurrence means um for any particular diagnosis, it covers a ninety-day time span.
[AGENT][NEUTRAL] So within that 90 days, if you're treated on multiple, multiple times for the same condition, it's $500.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it. And so these two payments for the.
[CUSTOMER][NEUTRAL] [PII] date totaled out to $232.33. Does that mean that the remaining between that and the $500 was already previously paid out or something?
[AGENT][NEUTRAL] That's correct. Claims that we pay claims on for [PII] data service.
[AGENT][NEUTRAL] And also.
[AGENT][NEUTRAL] One moment, let me add this up.
[AGENT][NEUTRAL] OK, so yeah, that $267.67 payment on [PII].
[AGENT][NEUTRAL] And then those other two payments that we made, the 60, excuse me, $8973 and the 14,260 was the $500 for that 90 day time frame.
[CUSTOMER][NEUTRAL] OK, understood.
[CUSTOMER][NEUTRAL] OK, um, the main thing we wanted to confirm was the claim actually got there and was processed and everything, um, I think the next thing we need to do is follow up with the.
[CUSTOMER][NEUTRAL] The provider because.
[CUSTOMER][NEUTRAL] On their billing statement, it seems that the members still getting billed what was shown as the
[CUSTOMER][NEUTRAL] Um, the allowed amount under the primary plan, but they're showing that this payment was received, but they're not really reducing.
[CUSTOMER][NEUTRAL] The amount they're billing so I think it's more of a billing issue really but.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, well, um, [PII], I don't know, did you have any other questions related to this coverage or that payment? No, mm mm, no. OK.
[CUSTOMER][NEUTRAL] Uh, uh, it was [PII], right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Oh, OK, perfect. Um, thank you very much. I think that answers all of our questions for right now. Thank you.
[AGENT][POSITIVE] OK, well thank you for calling APL you have a good day.
[CUSTOMER][POSITIVE] You too thanks.
[AGENT][NEUTRAL] Mhm bye bye.
[CUSTOMER][NEUTRAL] Bye-bye. Um.