AccountId: 011433970860
ContactId: a68023dd-0581-4869-9595-2470eabc6fc7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 699479 ms
Total Talk Time (AGENT): 202908 ms
Total Talk Time (CUSTOMER): 120378 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/15/a68023dd-0581-4869-9595-2470eabc6fc7_20250115T21:20_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] and I'm calling from the provider's office checking on status of a claim.
[AGENT][NEUTRAL] OK, sure, I can assist you with claim status, Mr. [PII], and may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] 02520427.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK. What's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK, and that was [PII], correct?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Can I have your name please?
[AGENT][NEUTRAL] Yes, my name is [PII]. That's [PII]. Last initial is [PII].
[AGENT][NEUTRAL] I see.
[AGENT][NEUTRAL] What is the procedure code?
[CUSTOMER][NEUTRAL] It is 992149300036415.
[AGENT][NEUTRAL] OK, so it was processed twice. The most recent one was processed as a duplicate, so I'm gonna pull the original one and give you the information on that one, OK?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so the original one was processed on [PII].
[AGENT][NEUTRAL] And we send a benefit amount of $75 to the provider.
[AGENT][NEUTRAL] $75 is the maximum benefit for that date of service.
[CUSTOMER][NEUTRAL] Is it a member responsibility?
[AGENT][NEUTRAL] Any remaining balance? Yes, it's up to the provider's discretion, but there's no more benefits, so that is the maximum benefit for the date of service, the $75 which is what we send out. This is an indemnity plan.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] It's an indemnity plan.
[AGENT][NEUTRAL] Yes, which means it just pays flat amounts.
[CUSTOMER][NEUTRAL] But there were 3 lines on the claims that, did each line pay or just 1 line paid?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, uh, only one line paid because we only pay uh for the office visit, and that is the $75 that we send out the office visit benefit.
[CUSTOMER][NEUTRAL] And the remaining uh lines are they are denying for non-covered service.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, oh, you said it's an inde indemnity plan. So what are the things covered services covered under the indemnity plan?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so this is not a guarantee of payment, just a verification of coverage and that's just a disclaimer. This one pays for hospital admission, hospital confinement.
[AGENT][NEUTRAL] Office visits.
[AGENT][NEUTRAL] And surgery.
[CUSTOMER][NEUTRAL] You said I'm sorry, uh, you said this way for office visit.
[AGENT][NEUTRAL] Yeah, it covers $75 per visit, maximum of 4 visits per person per calendar year.
[CUSTOMER][NEUTRAL] OK. And you said it says in in, and you said only for covers hospital visit and the hospital? I said some.
[AGENT][NEUTRAL] Hospital indemnity plan, correct. This is a hospital indemnity plan.
[CUSTOMER][NEUTRAL] So it covers only hospital office with its, uh, other, other services are not covered.
[AGENT][NEUTRAL] It covers hospitalization, office visits, and surgery.
[AGENT][NEGATIVE] So when puncture is not covered.
[AGENT][NEUTRAL] And any other um procedures done in the office is not covered, just the office visit. So this office visit was paid at $75 which is the maximum benefit. Again, we pay $75 for 4 visits per covered person per calendar year.
[CUSTOMER][NEUTRAL] And and only 4 offices with with the sacked.
[AGENT][POSITIVE] Per year, correct, yes.
[CUSTOMER][NEUTRAL] Uh, can I have the claim number please?
[AGENT][NEUTRAL] Sure. The claim number is 3537061.
[CUSTOMER][NEUTRAL] Can I have the check number?
[AGENT][NEUTRAL] Yes, check number is 2016666.
[CUSTOMER][NEUTRAL] Bulk or single?
[AGENT][NEUTRAL] It's a single check paper check.
[CUSTOMER][NEUTRAL] And, and it was sent to which address?
[AGENT][NEUTRAL] OK, this was sent to.
[AGENT][NEUTRAL] Bear with me.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, um, [PII].
[CUSTOMER][NEUTRAL] Has the check been cashed?
[AGENT][NEUTRAL] I have to check the system for that. Do you mind holding for me?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me, Mr. [PII]. OK, uh, um.
[AGENT][NEUTRAL] Check was cleared on [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Could you please fax us the copy of the EU for this claim or email?
[AGENT][NEUTRAL] What is
[AGENT][NEUTRAL] What is the fax number?
[CUSTOMER][NEUTRAL] 347
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 584
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Just one moment.
[CUSTOMER][NEUTRAL] 8354.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And to what attention?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] How do you spell that?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And, OK.
[AGENT][NEUTRAL] 01 moment. Let me
[AGENT][NEUTRAL] Fax this over one moment.
[AGENT][POSITIVE] OK. I went ahead and send that over to you. It should be there in a few minutes. Is there anything else I'm gonna help you with today?
[CUSTOMER][NEUTRAL] And would there be a reference number for this ca[PII]?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's name if you will.
[CUSTOMER][POSITIVE] Thank you, [PII].
[AGENT][POSITIVE] You're welcome and thank you for calling APL. Have a good day, Mr. [PII].
[CUSTOMER][POSITIVE] You too. Thank you. Goodbye.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm