AccountId: 011433970860
ContactId: 8ddc1089-ae2d-489b-a0c6-fdd3edf1692e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 441709 ms
Total Talk Time (AGENT): 210428 ms
Total Talk Time (CUSTOMER): 123791 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/8ddc1089-ae2d-489b-a0c6-fdd3edf1692e_20250121T15:57_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII]. I'm calling to check claim status for a member.
[AGENT][POSITIVE] Alright, 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] Yes, it's [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] I have.
[CUSTOMER][NEUTRAL] 02173596.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], date of birth is [PII], I'm sorry, [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you'd like me to check on?
[CUSTOMER][NEUTRAL] Um, yes, it's a date range from [PII].
[AGENT][NEUTRAL] OK, and the total bills?
[CUSTOMER][NEUTRAL] $2,159 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And again, just for the call, all the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment while I locate the claim for you.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Um, Northside Hospital.
[AGENT][NEUTRAL] OK, hold on one moment. 121. So I'm showing we received the claim on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That claim number is 343.
[AGENT][NEUTRAL] 6121.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Um, so we're requesting a more detailed explanation of benefits that shows the amounts that were applied to the deductible, co-pay and co-insurance. So we'll know what's left over to pay on.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Yes, but I'm not understanding. It's just a one page EOB and it, it has the $90.43 because on the back of the EOB we received from you guys, it says that we did receive it but we don't see it, but it's listed right there so I don't know how to make the primary insurance give us a different EOB. It says $90.43 on the front page.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hold on 1 2nd.
[AGENT][NEUTRAL] I'm just looking at the documents that were received. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, but we only pay towards the copay, the deductible and the co-insurance, but all of that has zero there. So even though it shows the patient responsibility, what of that is the deductible co-pay because that's the only thing that we pay towards. Um, let me see.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, so if, if, if their primary, um, it's like a indemnity plan, so it only pays like they have an allotted amount so if it's not applied to the deductible the co-pay of the insurance is just patient responsibility and it needs to be sent to the member.
[AGENT][NEUTRAL] No, no, no, no. I'm just saying from the explanation of benefits that was received.
[AGENT][NEUTRAL] Like this is the explanation of benefits, but the deductible and the co-pay column all show 0. So that's why they're asking for an explanation of benefits that shows what those amounts were to get that patient responsibility. So, let me reach out to someone in um claims to see if there's another way to receive that document or to give you more information on what they're looking for because they're examining it.
[CUSTOMER][NEUTRAL] Right, I understand. Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, cause I understand what you guys are saying, but it's not applied to one of those. This member only has a limited plan, so it just hasn't allowed amount. They have exhausted their benefits, so that's why that $90 belonged to the patient. It's not necessary their copay or their deductible. It's like a, it's almost like a cost share.
[AGENT][NEUTRAL] Right, we have hospital indemnity policies. I follow you. Um, let me see what they, um, you know what, hold on one second.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let me reach out to claims. Do you mind if I place you on just a brief hold?
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] OK, hold on one moment. And before I do that, was there anything else I can help you with because they're gonna ask me to transfer.
[CUSTOMER][NEUTRAL] They say
[AGENT][NEUTRAL] Alright well thanks for calling APL. Hold on one moment, OK?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I mean, what would I be putting in the chat?
[AGENT][NEGATIVE] I'm calling claims. She needs to talk to somebody. I'm not doing this. Like we need to help these people. Um, what type of policy is this? I'm not, I'm not gonna turn her away because she's trying to figure it out. Min.
[AGENT][NEUTRAL] And they're gonna ask me if the EOB is there and I'm gonna tell them I'm calling claims.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] This is easy.
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you?
[CUSTOMER][POSITIVE] I'm good. How are you?
[AGENT][POSITIVE] I'm doing good. I have a provider on the other line that has a question about um the explanation of benefits that they provided for a claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, I went over the claim status with them and I explained what we were looking for, but she's saying it's a hospital indemnity policy, so they don't have anything that's paid towards the deductible or co-pay, and I didn't know where to go from there.
[CUSTOMER][NEUTRAL] OK. What's the policy number?
[AGENT][NEUTRAL] Um, it's 217-359-6.
[CUSTOMER][NEUTRAL] OK, and who's the patient?
[AGENT][NEUTRAL] Um, oh, hold on, let me go.
[AGENT][NEUTRAL] It's number one, I forgot the name, [PII].
[CUSTOMER][NEUTRAL] OK. And her name, the caller's name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] OK. All right, you can send her over, we'll figure it out.
[AGENT][NEUTRAL] All right, thank you, [PII]. Hold on one moment.
[CUSTOMER][POSITIVE] Mhm. No problem.
[AGENT][POSITIVE] Hello [PII]. Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.