AccountId: 011433970860
ContactId: ab91dc58-9bea-4760-aac2-bf7528e86f29
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 511959 ms
Total Talk Time (AGENT): 219330 ms
Total Talk Time (CUSTOMER): 207093 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/28/ab91dc58-9bea-4760-aac2-bf7528e86f29_20250128T16:16_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Good morning [PII]. My name is [PII]. I am calling from a provider's office for claim status and verification of benefits.
[AGENT][POSITIVE] Alright, I'm happy to check on that for you today, [PII]. What is the patient's policy number?
[CUSTOMER][NEUTRAL] Yes, of course that is gonna be D40310374.
[AGENT][NEUTRAL] Um, do you have their name or social? I can't pull them with that number, unfortunately.
[CUSTOMER][NEUTRAL] Uh, let's take a look, yeah, let me look at her forms.
[CUSTOMER][NEUTRAL] Let's see what we've got here.
[CUSTOMER][NEUTRAL] Her social is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, thank you so much. Let me try that.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] All right. And what's the patient's first and last name?
[CUSTOMER][NEUTRAL] First name is [PII] and last name is [PII].
[AGENT][POSITIVE] All right, thank you so much. And are we looking for, is this medical or dental?
[CUSTOMER][NEUTRAL] Uh, medical.
[AGENT][NEUTRAL] Medical, OK. And then what is uh [PII]'s date of birth, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Alright, thank you so much. So her plan is active. The effective date on this is [PII].
[AGENT][NEUTRAL] And then what is the date of service?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the first, oh my, the first day of service um is gonna be I know is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then do we have
[CUSTOMER][NEUTRAL] And we got a denial stating that max benefits have been reached, so that's kind of why I'm trying to verify the benefits to see what exactly happened.
[AGENT][NEUTRAL] OK, do you have the claim number? I can pull it up.
[CUSTOMER][NEUTRAL] Uh, yes, of course, let me get to that screen. I got like 4000 screens open.
[CUSTOMER][NEUTRAL] OK, let's see, that's 116, just give me one moment, let's see here.
[AGENT][POSITIVE] No worries.
[AGENT][NEUTRAL] Looks like there's just, I think.
[CUSTOMER][NEUTRAL] All right, we've got
[CUSTOMER][POSITIVE] Uh, this is for data service perfect so claim number.
[CUSTOMER][NEUTRAL] Where are you? 02571217, I believe that's the claim number.
[CUSTOMER][NEUTRAL] No, I'm sorry, ma'am, that is not.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] Let me give you the correct one, it's 3552712.
[AGENT][POSITIVE] All right, thank you.
[CUSTOMER][NEUTRAL] These ELBs are a little different than what I'm used to.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] All right, let's see, OK, I see that so it looks like it.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Maximum benefit payable for the data.
[CUSTOMER][NEUTRAL] For the
[AGENT][NEUTRAL] See.
[AGENT][NEUTRAL] OK. So for outpatient.
[AGENT][NEUTRAL] It looks like office visit, the benefit amount is the $50. So that was the max for that. It wasn't gonna pay anything additional towards the office visit.
[AGENT][NEUTRAL] Um, and then, yeah, let's see.
[CUSTOMER][NEUTRAL] Oh my.
[AGENT][NEUTRAL] I don't know what this other.
[CUSTOMER][NEUTRAL] So that office visit was you received that claim for the office visit?
[AGENT][NEUTRAL] Mhm. And then the $50 was paid, yeah, it was paid towards that. And then the plan has like an accident and sickness surgical benefit.
[CUSTOMER][NEUTRAL] On [PII].
[AGENT][NEUTRAL] And it paid 5 or excuse me, it paid um.
[AGENT][NEUTRAL] For a physician's office and there's 2 a year that they get and then it just pays a benefit amount of 250.
[AGENT][NEUTRAL] So that
[AGENT][NEUTRAL] Was paid
[CUSTOMER][NEGATIVE] I don't think we've received.
[CUSTOMER][NEUTRAL] Oh it was.
[AGENT][NEUTRAL] Yeah, so I show on the claim itself there was a total benefit payment sent of $300 so it looks like it would have been $50 towards the um.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Visit and then there was
[AGENT][NEUTRAL] Physician's office for like surgical and then it shows 250 towards that.
[CUSTOMER][NEUTRAL] OK, I see. So yeah, for that one ultrasound on [PII] we got the $50 payment and then there's only another $250 available right for that other visit. Now let me see if we got that payment for 123. I don't show that oh there it is. I found it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] At least a portion. OK, so that wow so this.
[CUSTOMER][NEUTRAL] What kind of plan is this? Is it only.
[CUSTOMER][NEUTRAL] Is it like do they cover hospital stays at least or?
[AGENT][NEUTRAL] Yeah, so they do it's what they call a limited benefit hospital indemnity plan, so it just pays a set amount depending upon what they're being seen for it's not like a major medical where it's paying a percentage of cost or or anything like that, so it is different.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Wow, so it's almost like you wanna use this as a secondary versus a primary.
[AGENT][NEUTRAL] Yeah, a lot of people do. I mean, if they were admitted to the hospital, like it pays like a set flat fee of $500 for one hospital admission, um,
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] Yeah, it's a lot different than I think most people are used to with like a PPO or something.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Exactly so OK um.
[CUSTOMER][NEUTRAL] Now the remaining balance obviously will be the patient's responsibility correct? because.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Do you guys um apply contractual adjustments or is it just like that flat rate?
[AGENT][NEUTRAL] Yeah, I mean it's just that set amount benefit amount that gets paid towards it. We don't advise [PII], you know, on the patient responsibility. I mean that's obvious that's up to the facility or the provider, you know.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, well, yeah.
[AGENT][NEUTRAL] Cause we, we don't know if they have, we don't know if they have any other insurance or anything like that either, you know.
[CUSTOMER][NEUTRAL] OK, OK, perfect, and um, wow, OK, so I will look into this more. I know that she's got an Aetna policy, uh, but I gotta confirm that effective date. I'm hoping maybe it's for [PII] as well, so, um, and you stated that they already paid the 50 on that.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yes, I'm gonna have to wait on that one, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK great well thank you so so just just to clarify, we've got $50 is paid to the office visit outpatient office visit per year and then a total of $250 was applied towards that one visit for 123 2024 totaling the $300 per year that the patient gets, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yeah, correct.
[CUSTOMER][POSITIVE] OK perfect got it OK well thank you so much [PII] for your help today. Is there a call reference number?
[AGENT][NEUTRAL] Yeah, absolutely call reference is gonna be my name with my last initial and then today's date. My last initial to my name is [PII].
[CUSTOMER][POSITIVE] Perfect all right well thank you so much you have a great day.
[AGENT][NEUTRAL] You too bye bye.
[CUSTOMER][NEUTRAL] OK