AccountId: 011433970860
ContactId: 97b1f8b3-fe53-4d5f-a44c-e378b8b56b04
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 924909 ms
Total Talk Time (AGENT): 315524 ms
Total Talk Time (CUSTOMER): 427779 ms
Interruptions: 8
Overall Sentiment: AGENT=0.5, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/30/97b1f8b3-fe53-4d5f-a44c-e378b8b56b04_20250430T22:12_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, yes, [PII], my name is [PII]. I was calling to try to reach the claims department. I just need to follow up on a couple of claims for a number, please.
[AGENT][NEUTRAL] OK, oh, I can definitely I can check on claims for you. We're just needing to view those statuses.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, yeah, I can check that. Uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, so that's gonna be [PII].
[AGENT][NEUTRAL] Thank you and then do you have the policy number?
[CUSTOMER][NEUTRAL] Yes, uh, so let me put that up here. So I have that ID number as 023343778.
[AGENT][NEUTRAL] OK and uh what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Perfect, thank you for verifying that and what was the date of service for this claim?
[CUSTOMER][NEUTRAL] Uh, so the first date of service I wanted to look at it's for a single date, um, that's gonna be [PII] and the build amount is for 1100.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Was this with uh is it within health provider service?
[AGENT][NEUTRAL] Services.
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK. All right, one moment.
[AGENT][NEUTRAL] OK, so we did receive this claim and we were unable to pay a benefit as their outpatient benefit for the calendar year had been met.
[CUSTOMER][NEUTRAL] OK, hold on a second, let me make a note of that here.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, can you repeat that response just one more time for me, please?
[AGENT][NEUTRAL] Of course, yes, so their outpatient benefits for the calendar year had been met.
[AGENT][NEUTRAL] And if you'd like I can send you a copy of this EOB if you need that.
[CUSTOMER][NEUTRAL] Yeah, I would really appreciate getting that because that would really help me with um just communicating that to the patient. And I just had one question, um, as far as like uh what it's saying that it's reached the outpatient benefit for the calendar year, um, so it's based on how much they're allowed to cover as the secondary for the member, correct?
[AGENT][NEUTRAL] Of course.
[AGENT][POSITIVE] Absolutely, yes.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Correct, so their outpatient benefit for this policy is $3000 max per calendar year.
[CUSTOMER][POSITIVE] Got it. OK, good.
[CUSTOMER][NEUTRAL] For calendar year and let me provide you with our direct fax um so we can get that sent over and do you know approximately how.
[AGENT][POSITIVE] Sure, yeah, I'm ready when you are.
[AGENT][NEUTRAL] Oh sorry, go ahead.
[CUSTOMER][NEUTRAL] Um, do you know how like soon we would get that, that fax from you all?
[AGENT][NEUTRAL] Um, I would say within about 10 minutes or so I can go ahead and send it right now.
[CUSTOMER][POSITIVE] Oh my God, that would be awesome. Um, yes, so that's number is [PII].
[AGENT][NEUTRAL] OK, I'm going to read that back to make sure I heard that correctly. That was [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, that's right. And when exactly did they come back with that response?
[AGENT][NEUTRAL] OK, I will go ahead and get that sent.
[AGENT][NEUTRAL] Oh sure, let me see when that was uh received and processed.
[AGENT][NEUTRAL] OK, so this claim was processed [PII].
[CUSTOMER][NEUTRAL] OK, so I'm pretty sure that is what's going on with this other claim. Um, can we also just double check for [PII] with the same bill amount? I think that's probably what's going on with this one too.
[AGENT][NEUTRAL] Sure, yeah, I can go ahead and check that for good measure. Just one moment.
[AGENT][NEUTRAL] Yes, OK, so we did receive that one as well and it is denied for the same reason. um, did you want me to send you this, uh, EOB as well?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then did you also want me to find when this one was uh processed?
[CUSTOMER][POSITIVE] Uh, yes, that would be great.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, so it looks like it was the same time, uh, so [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, let me just make a note of it here.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK, I'm just kind of looking over some data service and I don't know, uh, this is probably gonna help my case, but of course that's why we're calling to see um so we have a data service, um, we actually, I, I'm actually seeing four claims that have a similar um situation going on, um, [PII] that has the same build amount.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me go and check that.
[CUSTOMER][NEUTRAL] This one looks like it processed and paid 6:40.
[CUSTOMER][NEUTRAL] Um, let me see, let me pull up the EFP on this phone.
[AGENT][NEUTRAL] OK, I'm sorry, that was [PII]?
[CUSTOMER][POSITIVE] Yes, that's right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK, so I do see a claim for the same amount, but I'm not showing that we paid a benefit.
[CUSTOMER][NEGATIVE] Really, it doesn't show anything just yet.
[AGENT][NEUTRAL] Yes, it was denied for the same reason. Correct, it was denied for the same reason.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] On [PII] also.
[AGENT][NEUTRAL] Uh, let me verify that.
[AGENT][NEUTRAL] Yes, that was also [PII].
[AGENT][NEUTRAL] Looks like we received several claims around that time.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Strange because it was almost as if we got paid or we got overpaid for that claim.
[AGENT][NEUTRAL] Uh, this is the only claim that I'm showing for the state of service. This was all for [PII], correct?
[CUSTOMER][NEUTRAL] Uh, what is going on?
[CUSTOMER][POSITIVE] Correct, that's right.
[AGENT][NEUTRAL] OK, yeah, this is the only claim I have that we've received uh for this state of service for her.
[CUSTOMER][NEUTRAL] Yeah, yeah, because we were submitting them, um, as a secondary, so.
[CUSTOMER][NEUTRAL] That's strange because it was almost like our clearing house was telling us that we got paid for $640 but we were only seeking to cover $160 worth of member responsibility that was being applied so I was like thinking if we send that back, does it apply some sort of credit to the other data service.
[AGENT][NEUTRAL] Sure, yeah, I'm not showing that we receive or that we uh made a payment for this one.
[CUSTOMER][POSITIVE] Interesting.
[CUSTOMER][NEUTRAL] I want to 9. That is true.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK then, then it's gonna it's this is having me so I can get the rest of the claims. Let me do this, um, can we, uh, review the data service for [PII]?
[AGENT][NEUTRAL] Yes, was that for the same amount?
[CUSTOMER][NEUTRAL] Yes, for 1100.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh just to make sure, [PII], this was all for the same or from the same provider correct?
[CUSTOMER][POSITIVE] That's correct, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I do have one claim for that date of service from this provider. Uh, it was for the benefit of $800 though, and we did pay that benefit.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][POSITIVE] OK, OK, great, so that one is like that's that's what we have. OK, awesome and then.
[AGENT][NEUTRAL] I was going to say um I don't know if it would be whatever is easier for you. I mean we can definitely go through um each one but it looks to me that a lot of these claims that were processed on the [PII] were from this provider and we did pay several.
[CUSTOMER][NEUTRAL] Yeah, yeah, and, and, and that's what I was because, um, since he gave me that uh response for [PII], I'm like, OK, I'm downing them because a lot of them we do see that process and paid um for the full member responsibility that was applied by the primary like.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, yes.
[CUSTOMER][NEUTRAL] Um, 52, um, single date for 57.
[CUSTOMER][NEUTRAL] 58595 10 and 513.
[AGENT][NEUTRAL] Let's see
[CUSTOMER][NEUTRAL] Look like it's all paid.
[AGENT][NEUTRAL] Hold on.
[AGENT][NEUTRAL] Yes, and I see the it looks like the one that met the maximum was for $515 that benefit the billed amount we received was $160 we paid $131.77 and that's the one that met her maximum.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] 131 77.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mets.
[CUSTOMER][NEUTRAL] Yeah, uh, maximum.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the phone, OK, and then I know 5148 0.
[CUSTOMER][NEUTRAL] Payments on that one.
[CUSTOMER][NEUTRAL] Let's see here.
[CUSTOMER][NEUTRAL] Sorry, give me one second because I do not want to put you through going through all of those like that, um.
[AGENT][NEUTRAL] That's fine.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so then that's the maximum of 5:15. Does this show any payment coming in through 5:16?
[AGENT][NEUTRAL] For a claim from 516?
[CUSTOMER][NEUTRAL] Uh, 5:16.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] I do see a claim received then um for 1100.
[CUSTOMER][NEUTRAL] OK, so I.
[AGENT][NEUTRAL] But we did not make a payment for that claim.
[CUSTOMER][NEUTRAL] OK, but
[CUSTOMER][NEUTRAL] OK, that's fine and mhm.
[AGENT][NEUTRAL] And to add to some of the confusion and I do apologize um of course the way that it pays is going to be in the order in which the claims were received, not necessarily the date of service, so that's maybe where some confusion is.
[CUSTOMER][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] OK, just wanted to make sure you were aware, OK.
[CUSTOMER][NEUTRAL] Oh no no no no no yeah no we understand that.
[CUSTOMER][NEUTRAL] No, we understand that because.
[CUSTOMER][NEUTRAL] That's why uh those stood out to me because claims before and after process and paid for the full so that's why I kind of wanted to look that over, um.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, so then let me look at uh for data service 517 of 24. I'm assuming nothing has been paid on that claim, right?
[AGENT][POSITIVE] Correct, yes, I do see that one as well for 1100.
[CUSTOMER][NEUTRAL] OK, so nothing was paid on that.
[CUSTOMER][NEUTRAL] Fine.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then I don't know if you're able to look at it as a date range um but we have like 5 different claims between 5:20 and 5:30. It looks like those paid.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, the total like expected amount of $800 per day, does this show there on your end?
[AGENT][NEUTRAL] Let's see what what was the date range? I'm sorry.
[CUSTOMER][NEUTRAL] Uh, between [PII] and [PII].
[AGENT][NEUTRAL] [PII]. OK, let's just, I'm going to do this. I'm just gonna take a look at all of them because I'm pretty sure I can see which ones are from you. OK, so we're going to be kind of going backwards so I apologize but I can let you know um.
[CUSTOMER][NEGATIVE] Oh no.
[AGENT][NEUTRAL] Each date, uh, um, what was paid, give me just a moment.
[AGENT][NEUTRAL] OK, so from [PII] we have one that was for $291.51 and we paid that.
[AGENT][NEUTRAL] 528 of 2024 for $320 and we did pay that.
[AGENT][NEUTRAL] And then it goes to 523 of 24 for 320 we paid that.
[AGENT][NEUTRAL] 521 of 2024 for $160 and that was paid as well as $520 of $24 also for $160 which we did pay.
[CUSTOMER][NEUTRAL] $160. OK, OK, great. All right, so I'm gonna make a note of that there.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK great so it did pay for the member responsibility. We were just a little afraid that it was paying for what the allowed amount was and that's not exactly what we were submitting the OB for, but I have it here, yeah, OK, great, um, I think that's gonna be everything that I need, [PII], um, can I just get a reference number for the call?
[AGENT][NEUTRAL] Oh yes, right, right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, that would just be my first name, last initial, and today's date and so my name is spelled [PII] Was there anything else I could help you with that [PII]?
[CUSTOMER][POSITIVE] Um, no, I think that's everything that I need. Thank you so much.
[AGENT][POSITIVE] All right yeah thanks for giving us a call. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Thank you you as well.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] OK.