AccountId: 011433970860
ContactId: b119b7b7-06db-4941-9fa1-c8d6f22079ab
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 390059 ms
Total Talk Time (AGENT): 131998 ms
Total Talk Time (CUSTOMER): 199626 ms
Interruptions: 3
Overall Sentiment: AGENT=2.1, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/b119b7b7-06db-4941-9fa1-c8d6f22079ab_20250117T21:33_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh hello, [PII]. My name is [PII], first initials [PII]. Um, I need uh information regarding a claim. I do have an EOB.
[AGENT][POSITIVE] Oh, it would be my pleasure to assist you.
[CUSTOMER][NEUTRAL] And we did receive payment.
[AGENT][NEUTRAL] All right, thank you. You said your name is [PII], is that correct?
[CUSTOMER][POSITIVE] Oh thank you.
[CUSTOMER][NEUTRAL] Oh, it is very, that is [PII]
[AGENT][POSITIVE] Oh, thank you, [PII]. And what is a good callback number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], what is the claim number if you have an EOB I can look everything up by that.
[CUSTOMER][NEUTRAL] Uh, let me go ahead and look at the EOP. I just had it here. Give me a second.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Claim number is 2013642.
[AGENT][NEUTRAL] Oh, that sounds, what's the patient's name?
[CUSTOMER][NEUTRAL] Oh, the patient's name, um, I don't know how to pronounce it, but I can go ahead and spell it out.
[CUSTOMER][NEUTRAL] So first name is [PII]
[AGENT][NEUTRAL] And that's not pulling up. You said claim number 2013642?
[CUSTOMER][NEUTRAL] Let me go ahead and open this maybe hopefully I'm just offer number.
[AGENT][NEUTRAL] Because that's not pulling up that patient. And I thought it sounded like it was actually a policy number, so I tried by policy number and that's not pulling up that name either.
[CUSTOMER][NEUTRAL] Oh, I see. OK. So, uh, I do have a policy number.
[CUSTOMER][NEUTRAL] Oh, there's 2.
[CUSTOMER][NEUTRAL] Hm, OK. So I might give you the incorrect claim number.
[AGENT][POSITIVE] OK, let's, you got another one? Let's try it.
[CUSTOMER][NEUTRAL] Uh yes, I think it's this 1, uh, 352-979-9.
[AGENT][NEUTRAL] OK, now I see why you were spelling that name.
[CUSTOMER][POSITIVE] Oh, perfect. Yes, I was looking at the policy number, but I'm assuming I gave you a number off as well.
[AGENT][POSITIVE] No problem at all. And what is
[AGENT][NEUTRAL] The patient's date of birth.
[CUSTOMER][NEUTRAL] Oh, date of birth, right, the name, it's so hard for me. I've tried, I'm like, I think I have the name of.
[AGENT][NEUTRAL] I was try I I.
[AGENT][NEUTRAL] Yeah, I looked at it to. I don't know.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I didn't want to confuse you more. OK, let me just go ahead and spell it out. Um, did you need the date of birth?
[AGENT][POSITIVE] Good deal. And last name is [PII].
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] Oh yeah. So then even that was so hard for me. I'm like, I don't want to mess it up. Uh yeah, well, the date of birth is [PII].
[AGENT][NEUTRAL] All right, thank you. And this is for data service [PII]?
[CUSTOMER][POSITIVE] Yes, that is correct.
[AGENT][NEUTRAL] Alright, I do have that claim pulled up. How can I help you, [PII]?
[CUSTOMER][NEUTRAL] OK, so I just need a more clarification um.
[CUSTOMER][NEUTRAL] Our facility and our contract, we have that we have an expected allowable of $2,151.50. However, um I do see that the ER visits are covered for $50 which, which we did receive a payment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] So, in this case, um, it was the remaining not allowable.
[AGENT][NEUTRAL] So with this policy, it is a limited indemnity policy. It's not a major medical, and the maximum benefit we can pay per day for an ER visit is $50.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right. Uh, so then in this case, um,
[CUSTOMER][NEUTRAL] The denied amount, uh, is that part of the, I, they, we have it here in our system as patient responsibility. Be if it has, uh, each maximum, um, I think I'm a little off, but is this transferred to self-pay to the patient?
[AGENT][NEUTRAL] So that would be determined by the provider because we're not major medical, we don't determine patient responsibility and with APL there's no contractual contractual involvement in the processing of the claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me go there but.
[CUSTOMER][NEUTRAL] You said there's no contractual.
[AGENT][NEUTRAL] Involvement in the process, yeah, in the processing of the claim, that's correct.
[CUSTOMER][NEUTRAL] Involvement, right?
[CUSTOMER][NEUTRAL] OK, I see, yeah. So.
[CUSTOMER][NEUTRAL] Hm. OK. So then I'm gonna go ahead and reach out to my supervisors, um.
[CUSTOMER][NEUTRAL] But um regarding that up to the provider which is uh to see if we uh just transfer to patient responsibility.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK. All right. I believe I'm understanding. Can I get the first initial of your last name?
[AGENT][NEUTRAL] It it's [PII]. Do I need to spell my first name for you?
[CUSTOMER][NEUTRAL] Um, I have [PII], right?
[AGENT][NEUTRAL] Mhm. It's [PII]
[CUSTOMER][NEUTRAL] Oh yeah, yeah, I got it correct. OK, I'll just go ahead and get a reference number.
[AGENT][POSITIVE] Reference number is my name and today's date, and I, it's been a pleasure to assist you with that um claim information. Anything else I can help you with today?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Uh, no, that'll be it. Thank you.
[AGENT][POSITIVE] No, thank you for calling APL. Hope you have a lovely day.
[CUSTOMER][POSITIVE] You too. You have a nice weekend.
[AGENT][POSITIVE] You too, very thank you for calling APL. Take care.
[CUSTOMER][NEUTRAL] OK, you too. Bye-bye.
[AGENT][NEUTRAL] Bye-bye.