AccountId: 011433970860
ContactId: 92cfa651-d22c-43fe-97e5-260f95c68f6c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 354519 ms
Total Talk Time (AGENT): 136715 ms
Total Talk Time (CUSTOMER): 131129 ms
Interruptions: 0
Overall Sentiment: AGENT=0.1, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/27/92cfa651-d22c-43fe-97e5-260f95c68f6c_20250227T13:13_UTC.wav
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[AGENT][NEUTRAL] PL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I am calling with the provider's office. um I want to get an update on an appeal that we submitted.
[AGENT][NEUTRAL] OK, I can help you, [PII]. What's the policy number?
[CUSTOMER][NEUTRAL] It's 02388488.
[AGENT][NEUTRAL] And if I can get a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you for that. And what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII], um, his last name is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And his date of birth.
[CUSTOMER][NEUTRAL] And then date of birth is [PII].
[AGENT][POSITIVE] All right, thanks for that, [PII].
[AGENT][NEUTRAL] And when did you submit the appeal?
[CUSTOMER][NEUTRAL] Um, it looks like it was submitted.
[CUSTOMER][NEUTRAL] Let me click this off.
[CUSTOMER][NEUTRAL] It would have been early January.
[AGENT][NEUTRAL] And uh regarding which date of service?
[CUSTOMER][NEUTRAL] Um, data service is [PII].
[CUSTOMER][NEUTRAL] Of last year.
[AGENT][NEUTRAL] What was the amount of the claim?
[CUSTOMER][NEUTRAL] Um, total charge is 983.
[AGENT][NEGATIVE] OK now I'm not showing an appeal has been received. I show the claim processed and paid, but I don't show an appeal.
[CUSTOMER][NEUTRAL] Um, it paid, it only paid $50 on the [PII] for the office visit. Nothing paid on the other code, but $50 is very, very low, so it looks like that's why she appealed it.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] When she, who are you referring to?
[CUSTOMER][NEUTRAL] Um, the appeals analyst.
[AGENT][NEUTRAL] OK. And so this is a limited hospital indemnity plan. And so the maximum benefit for the patient's policy is up to $50 per day, per calendar day. So that's the maximum, um, just so you know, of course, we'll review the appeal, but more than likely it'll be upheld because the policy benefit is what was paid.
[CUSTOMER][NEUTRAL] OK, so up to $50 max daily like.
[AGENT][NEUTRAL] Per calendar day.
[CUSTOMER][NEUTRAL] Um, is that like for anything they get done $50?
[AGENT][NEUTRAL] During the visit, yes. And so in this instance, it was applied towards that physician's fee.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Office.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so it doesn't matter what they get done that day, it's $50 and then is the patient responsible for the difference?
[AGENT][NEUTRAL] We do not determine the patient's responsibility. I believe on the ELB it states that the $50 is the maximum benefit, so that benefit is exhausted for that day.
[CUSTOMER][NEUTRAL] Um, let me, yeah, I don't think it does say. I just looked at it.
[AGENT][NEUTRAL] It's on the back of it, of the ELB.
[CUSTOMER][NEUTRAL] Oh, I'm looking in, um, in our clearing house, so I can't see the back of it. It only shows the front.
[AGENT][NEUTRAL] Yeah, so that's on the explanation of benefits that was mailed to the provider's office. Um, the second page states that the $50 is the maximum benefit per day.
[CUSTOMER][NEUTRAL] OK, OK, um, and you called this what a limited plan?
[AGENT][NEUTRAL] A limited hospital indemnity plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what was your name?
[AGENT][NEUTRAL] You'll use my name in today's date as reference for today's call, [PII]. Did you have any other questions?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, in case for some reason about appealing it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What is the correct, maybe it didn't get sent to the right place?
[AGENT][NEUTRAL] Mhm and so it'll be the same claims address as the claim was submitted, which is [PII].
[AGENT][NEUTRAL] 248
[AGENT][NEUTRAL] 950.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Attention appeals.
[CUSTOMER][NEUTRAL] OK. Is there a form or just do a cover letter?
[AGENT][NEUTRAL] Yeah just a cover letter, letter state the reason for the appeal and to provide any supporting documentation.
[AGENT][NEUTRAL] Which that's the maximum benefit, so more than likely it will be upheld.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Um,
[CUSTOMER][NEUTRAL] OK, and you did the reference number. Oh, do you guys have fax by chance or is it mail only?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] You can fax it, it's 877.
[AGENT][NEUTRAL] 365.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 942 3.
[AGENT][NEUTRAL] And then if you could put attention claims slash appeals.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Gotcha.
[CUSTOMER][POSITIVE] OK, thank you so much and you have a great day.
[AGENT][POSITIVE] You too [PII] thank you for calling APL. Have a good day as well.
[CUSTOMER][NEUTRAL] Uh bye-bye.
[AGENT][NEUTRAL] Bye bye.