AccountId: 011433970860
ContactId: a0f1763e-32af-44bf-9780-f9d3b9506960
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 470630 ms
Total Talk Time (AGENT): 151649 ms
Total Talk Time (CUSTOMER): 128498 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/21/a0f1763e-32af-44bf-9780-f9d3b9506960_20250221T13:31_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] Hello, good morning, [PII]. My name is [PII], and I was calling on behalf of a facility, and I was calling to see what network uh claim was processed under.
[AGENT][NEUTRAL] What network? What do you mean network?
[CUSTOMER][NEUTRAL] Um, it's trying to see if you guys use the multi-plan network to process a claim.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, well, I'll be more than happy to assist you. And may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh-huh, my name is [PII]. The spelling of it is [PII] and my direct number is [PII].
[AGENT][NEUTRAL] Thank you and [PII], may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, it is 2586493.
[AGENT][NEUTRAL] Hold on one moment. After the 25, the phone went out and then I heard 93.
[CUSTOMER][NEUTRAL] OK, um, 2586493.
[AGENT][NEUTRAL] OK, 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] In the, um, [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 look at with you?
[CUSTOMER][NEUTRAL] Uh-huh. [PII].
[AGENT][NEUTRAL] And the total bills?
[CUSTOMER][NEUTRAL] $84,0007.48
[AGENT][NEUTRAL] Alright, sure it is OK if I place you on just a brief hold while I look for the claim for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So, just to make sure I have the dates right, you said [PII]?
[CUSTOMER][POSITIVE] That is correct.
[AGENT][NEUTRAL] OK, I just want to make sure because there's no claim on file for the that date range or each particular date. Where um where did you send the claim?
[CUSTOMER][NEUTRAL] Um, I do have a
[CUSTOMER][NEUTRAL] Well I have the claim number because you guys paid it it's just it was underpaid and I just wanted to make sure that um I wanted to see what um.
[CUSTOMER][NEUTRAL] Contract you guys use um I do have the claim number if you wanna pull it up that way it is 3,561,840.
[AGENT][NEUTRAL] OK. What's the claim number?
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, that's a different policy number. OK, hold on, let me pull that up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That was processed under 231-1714. Hold on one second, I'm gonna go there.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, what's the claim number 840.
[AGENT][NEUTRAL] OK, let me see why was it underpaid.
[AGENT][NEUTRAL] Hold on one second, I'm in the claim now.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I'm just gonna place you on another brief hold if you don't mind that I'm in the right place and I'm gonna look at the claim and why it was denied and how it was processed.
[CUSTOMER][POSITIVE] OK, thanks.
[AGENT][NEUTRAL] All right, you're welcome. Hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 00 wait, I don't need to do that.
[AGENT][NEUTRAL] OK. Thank you so much for holding again. I apologize for that wait. So, it was processed using the multi-plan and their hospital indemnity benefits. Multiplan does the repricing, but the reason that it was underpaid is because the max of the the MRI and the surgery benefit was met, so it couldn't be paid out on for this claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] OK, so you guys are not leaving any patient responsibility even though it reached its max.
[AGENT][NEUTRAL] Well, we don't determine patient responsibility because we're not the major a major medical insurance company.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK. All right. OK, that's all the information I need. I just want to make sure before I did submit a um underpayment appeal, um, and with the appeal, I can just send that by mail or by fax?
[AGENT][NEUTRAL] Um, you can fax it or you can, whichever one you prefer.
[CUSTOMER][NEUTRAL] OK, what's the fax number because I have the address, but I'd rather fax it because I can get a confirmation.
[AGENT][NEUTRAL] Let me see. This is hospital indemnity. So let me make sure on the facts. Hold on one second. So my apologies for hospital indemnity, um, I forgot it was hospital indemnity, my apologies. It's only mail or payer ID.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and that mailing address [PII].
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][POSITIVE] Got it. OK. All right. Well, thank you so much. I really do appreciate it. And can I have your name and a reference number?
[AGENT][NEUTRAL] Yes, so there's no call reference number, but you can use my name, which is [PII], first initial [PII] my [PII] name is [PII], and then today's date.
[CUSTOMER][POSITIVE] Got it. All right. Thank you so much, [PII], and I hope you have a wonderful day.
[AGENT][POSITIVE] You're welcome, [PII]. You also, and thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Bye-bye.