AccountId: 011433970860
ContactId: 91249f28-0dc2-451b-ab51-3f671bae44d3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 505600 ms
Total Talk Time (AGENT): 158385 ms
Total Talk Time (CUSTOMER): 189330 ms
Interruptions: 3
Overall Sentiment: AGENT=0.4, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/11/91249f28-0dc2-451b-ab51-3f671bae44d3_20250611T19:47_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from Advent Health to Rapid [PII] Center.
[AGENT][NEUTRAL] OK, I can verify claim status for you. And um yeah, what is the policy number?
[CUSTOMER][NEUTRAL] You.
[CUSTOMER][NEUTRAL] one.
[AGENT][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] The policy number is
[CUSTOMER][NEUTRAL] 02451577 M as in Mary, L as in Lima 8.
[AGENT][NEUTRAL] OK, thank you. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you one moment.
[AGENT][NEUTRAL] And verify the patient's name, date of birth.
[CUSTOMER][NEUTRAL] than.
[CUSTOMER][NEUTRAL] Patient name is [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. And date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And what was the date of service and the amount of the charge?
[CUSTOMER][NEUTRAL] They
[CUSTOMER][NEUTRAL] [PII] $15,472.47.
[AGENT][NEUTRAL] OK, and the balance after primary?
[CUSTOMER][NEUTRAL] What
[AGENT][NEUTRAL] And what is the balance after the primary?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] $500 even.
[AGENT][NEUTRAL] OK, one moment please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] And what's the uh what's the name of the provider's office?
[CUSTOMER][NEUTRAL] AdventHealth Orlando.
[AGENT][NEUTRAL] I
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] I can't give you.
[CUSTOMER][NEUTRAL] You done?
[AGENT][NEUTRAL] I'm here, give me one moment.
[CUSTOMER][NEUTRAL] And Apple and
[AGENT][NEUTRAL] I show the claim paid 2331 and with that payment, it matched their inpatient benefit for the year.
[CUSTOMER][NEUTRAL] OK. So, remaining balance needs to be billed to the patient or else what I need to do for this?
[AGENT][NEUTRAL] Uh, you need to contact the patient. I can't give patient responsibility. I can only verify how the claim was processed.
[CUSTOMER][NEUTRAL] Yeah. So, remaining balance needs to be adjusted or else we need to bill patient as they have exhausted the benefits.
[AGENT][NEUTRAL] Ma'am, as I just stated, I cannot give patient responsibility or tell you to write off anything. I can only verify how the claim was processed and we paid 2331 and with that payment, it matched their benefit for the year.
[CUSTOMER][NEUTRAL] One minute.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] So, shall we add any modifier to the claim and rebuild the claim?
[AGENT][NEUTRAL] If you rebuild the claim, it will just be processed as a duplicate. The claim processed and paid 2331, and with that payment, the insured met their benefit max for the year. So assume you need to contact the patient. We cannot give patient responsibility, ma'am. We can only verify how the claim was processed.
[CUSTOMER][NEUTRAL] One minute, please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, so,
[CUSTOMER][NEUTRAL] Shall I appeal with the medical records?
[AGENT][NEUTRAL] Ma'am, I don't know. You may need to talk to your office manager to see what their, uh, your next steps would be. I cannot tell you what to do. I can only verify the claim was processed.
[CUSTOMER][NEUTRAL] OK. Could you hold for a moment, please?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] May I get your name, please?
[AGENT][NEUTRAL] Sure, it's [PII] last initial [PII]
[CUSTOMER][NEUTRAL] So may I know if the benefits is $2000 right? Maximum benefits for the calendar year?
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] For, uh, inpatient, yes, they have a benefit max up to 2000 per calendar year.
[CUSTOMER][NEUTRAL] It was exhausted, right, with the payment of $23.31. So, if we, if we bill character claim also you won't pay for this claim, right?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] No, since they've met their benefit max, there's nothing else to pay.
[CUSTOMER][NEUTRAL] So, if the member has been met their benefits, max maximum benefits, then uh remaining balance uh is a patient liability, right?
[AGENT][NEUTRAL] Ma'am, I cannot tell you that, as I said it before, I can only verify how the claim was processed, which 2333 2331 was paid and with that payment it matched their benefits. I can't tell you that the balance is patient responsibility or if you write it all, I'm just telling you how the claim was processed. I don't know what the office would do, but that's.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Only thing we can explain.
[CUSTOMER][NEUTRAL] Yeah, in the UOB I got to know that uh in the UOB I got to know that bill amount is only $23.31. But we have billed the claim with the bill amount $15,472.47.
[CUSTOMER][NEUTRAL] So, could you check and let me know why it was deferred by the bill amount?
[AGENT][NEUTRAL] Because with that payment, it met their max for the year.
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] They have a benefit max of for inpatient up to 2000 per calendar year. They have other claims that have came to where they've used up their benefit and only 2331 was payable for this claim. So with the claim it maxed their benefit.
[CUSTOMER][NEUTRAL] Well let me
[CUSTOMER][NEUTRAL] Other not lemon tea.
[CUSTOMER][NEUTRAL] OK. May I get the call reference number?
[AGENT][NEUTRAL] You may use my name at today's date if you like.
[CUSTOMER][POSITIVE] OK. Thank you. Bye-bye.
[AGENT][NEUTRAL] Mhm