AccountId: 011433970860
ContactId: a581e4b8-9f17-4302-8ec7-f29abef8f279
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 391440 ms
Total Talk Time (AGENT): 178117 ms
Total Talk Time (CUSTOMER): 114303 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/a581e4b8-9f17-4302-8ec7-f29abef8f279_20250123T16:34_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII] speaking. How may I help you?
[CUSTOMER][NEUTRAL] Yes, hi, my name is [PII]. I'm calling from Nicholas Children's Hospital following up on a claim.
[AGENT][NEUTRAL] Sure, I can help you with the claim status. Can I have a callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and can I please have the policy uh certificate number or member ID?
[CUSTOMER][NEUTRAL] It's 1395395 M as in Mary, L as in Larry, 8.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Just give me one moment please to pull up that policy.
[CUSTOMER][NEUTRAL] Of course.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And may I please have you verify patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yes, this is for [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what's the date of service and the amount on the claim, please?
[CUSTOMER][NEUTRAL] [PII] for $11,673.26.
[CUSTOMER][NEUTRAL] I also do have a claim number if that would be helpful.
[AGENT][NEUTRAL] Certainly you can go ahead and provide that please.
[CUSTOMER][NEUTRAL] 342-856-4
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And just give me one moment please.
[CUSTOMER][POSITIVE] Sure, thank you.
[AGENT][NEUTRAL] I'm just gonna pull that claim and then so take just a moment please.
[AGENT][NEUTRAL] OK, so we received that claim.
[AGENT][NEUTRAL] On, uh, [PII], [PII].
[AGENT][NEUTRAL] Claim process date is [PII]. It looks like we had requested the uh detailed explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] That's the reason why I'm calling. We, we actually had that that documentation faxed to you guys, so I'm wondering if you guys ever received it because we never got anything back.
[AGENT][NEUTRAL] I'm not showing.
[AGENT][NEUTRAL] We received the 2nd submission. Let me double check that. Just bear with me for one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Sure, thank you.
[AGENT][NEUTRAL] OK, so 351 69.
[AGENT][NEUTRAL] Let me look at that claim image because it does appear we received it a second time for that particular service so let me pull that image and see what it tells me.
[CUSTOMER][POSITIVE] OK thank you.
[AGENT][NEUTRAL] Because it looks like we're still needing the explanation of benefits, so let me just take a peek at that claim and determine because it looks like um on the first submission the claim uh received on that first submission we received the UBO4 we received a primary insurance remittance advice but it did not show any patient liability, so this policy is um.
[AGENT][NEUTRAL] Uh, limited supplemental of medical, so it does require, uh, that coinsurance and or deductible amounts need to show from that primary insurance. So in other words, if the primary insurance pays in full or that allowed amount is what the primary insurance paid and there's no co-insurance and or deductible, this policy will not, uh, pay. So on that first.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I understand, but I'm looking at, yeah, but I am looking at what was faxed to you guys and the EOB from the primary um specifies that there's a deductible of 1,79446. That's what was mailed to you guys, that was what was faxed to you guys.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And when was that faxed?
[CUSTOMER][NEUTRAL] Let me go back, give me one second.
[AGENT][NEUTRAL] Do you have a date?
[CUSTOMER][NEUTRAL] Yeah, let me go back and and look at that information.
[CUSTOMER][NEUTRAL] Just give me one second because I have to go back, go back.
[CUSTOMER][NEUTRAL] OK, it was actually faxed on [PII].
[AGENT][NEUTRAL] OK, so I don't show that submission. I showed the second submission for this, uh, claim we received it on [PII], but all the only thing we received was the UBO4 form, so we didn't have that primary explanation of benefits, um, and I don't show a fax around that July, yeah, um.
[CUSTOMER][POSITIVE] That's incredible, OK.
[CUSTOMER][NEUTRAL] OK, can I get a reference number for this call? I'll go ahead and and refax this.
[AGENT][NEUTRAL] Do you wanna
[CUSTOMER][NEUTRAL] I have the fax number at [PII].
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Yes, that is the correct fax number.
[AGENT][NEUTRAL] Um, and then they call.
[CUSTOMER][NEUTRAL] I'll go ahead and refax it.
[AGENT][NEUTRAL] Yeah, and the call reference number [PII] is my name in today's date. My first name [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Last initial is [PII]
[AGENT][POSITIVE] Like love.
[CUSTOMER][POSITIVE] I like that. Thank you very much. You have a wonderful rest of your day.
[AGENT][NEUTRAL] Hm.
[AGENT][POSITIVE] You too thank you so much for calling APL. I hope you have a great rest of your day and a great weekend.
[CUSTOMER][NEUTRAL] Mhm bye bye you too bye.
[AGENT][POSITIVE] Bye bye thank you bye.