AccountId: 011433970860
ContactId: b55044a1-9d95-4738-9567-f7904dca007c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 439790 ms
Total Talk Time (AGENT): 220768 ms
Total Talk Time (CUSTOMER): 155284 ms
Interruptions: 4
Overall Sentiment: AGENT=0.9, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/19/b55044a1-9d95-4738-9567-f7904dca007c_20250519T14:38_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. Can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling from Adventist Health billing office, um, just to get a little bit of clarification on, uh, a few claims for a patient.
[AGENT][POSITIVE] Absolutely I could check those claims for you. uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] Extension [PII].
[AGENT][NEUTRAL] OK, thank you. Do you have the policy number?
[CUSTOMER][NEUTRAL] Um, yeah.
[CUSTOMER][NEUTRAL] 02421895.
[AGENT][NEUTRAL] OK and then what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] It's [PII], [PII].
[AGENT][NEUTRAL] Alright, thank you for verifying that and you did say we have multiple claims for the same number correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, were they 4 different dates of service?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, uh, whenever you're ready I can go ahead and take that first date of service.
[AGENT][NEUTRAL] Unless you have those claim numbers.
[CUSTOMER][NEUTRAL] Um, it's August
[CUSTOMER][NEUTRAL] Um, I have.
[CUSTOMER][NEUTRAL] One of the claim numbers.
[AGENT][NEUTRAL] OK, that's whatever is easier.
[CUSTOMER][NEUTRAL] Um, 1st, 1st one's, uh, claim number 359-82608260.
[AGENT][NEUTRAL] OK, I could go ahead and check that one. Give me just a moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so looks like this one has a couple of different items one registered as a duplicate, the other denied as their uh maximum benefit for the data service had been met. So before we go any further, just so that you are aware, um, kind of maybe ease any confusion, this is a limited indemnity medical plan.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it pays essentially a set dollar amount per covered procedure or office visit. The way this one particularly works is I believe I can double check exactly, um, but I think for visits like this, um, it pays a maximum benefit of $50 per calendar day, so that would be for the entire date of service, but I can get clarification on that. Give me just a moment let me check.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and I do think that's correct because I have a $50 payment here that hasn't been distributed and that would make sense. Um, and then does, does the rest of the balance go to the patient then?
[AGENT][NEUTRAL] Right. Yes, that's it.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] So we don't say what is patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So whenever you're ready I can I can check those other claims for you.
[CUSTOMER][NEUTRAL] Um, yes, my next one.
[CUSTOMER][NEUTRAL] Is September 17, 2024.
[CUSTOMER][NEUTRAL] And build out $563.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, so it looks like for this one, we did receive that claim a few times, so you might have gotten a couple of denials as duplicates, uh, but I did find the original and for the original we did pay a benefit of $50.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Did you need that uh claim number or the check information?
[CUSTOMER][NEUTRAL] Um, is it possible for you to send me the explanation of benefits for both of those, the orig, OK.
[AGENT][NEUTRAL] Absolutely, yeah, do you have, yeah, do you have a fax number?
[CUSTOMER][NEUTRAL] Um, I do.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It is 503.
[CUSTOMER][NEUTRAL] 261-6016
[CUSTOMER][NEUTRAL] And are you able to put attention to somebody?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Um, can you put attention [PII]
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, um, I'm gonna read that number back to you to make sure I heard that correctly. That was [PII].
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK, and you wanted this, uh, did you want this other, um, the first claim you wanted that one sent to you as well?
[CUSTOMER][NEUTRAL] Yeah, the original claim for that one. I have um one explanation of benefits where it's the duplicate.
[AGENT][NEUTRAL] OK, again this one did have um it looks like it was a couple of different uh items only one registered as a duplicate so let me.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Check that. Give me just a moment.
[AGENT][NEUTRAL] Was it for the procedure code 99203?
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] OK alrighty I will get that sent to you.
[CUSTOMER][POSITIVE] Perfect.
[AGENT][NEUTRAL] Well I might just do it all at once when we're done.
[AGENT][NEUTRAL] Um, you could go ahead with that next, um, well I was like that's gonna take too long, so what was that next data service Callie?
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Um, actually, those are the only two that I have. Um, and then just to get a little more clarification, so, um, the patient technically had or has 90 degree benefits. How does, how does that work with the two of, two of your
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] So there is quite a bit of confusion regarding that um so it's a part of a multi plan this policy they have with us again is that limited indemnity medical plan going to be more along the lines of um accident sickness, uh, hospital, surgical, things like that from what I understand.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 90 degree that plan is going to be more for wellness benefits, but I'm not 100% what else they might have um if you'd like I can give you 90 degrees of information like their phone number if you'd like to call them and ask. OK, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I actually did just, I just talked to them.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That's just what I understand it as.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] OK, that definitely helps. Um.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][POSITIVE] OK, I think that's all I need actually is just that makes a lot more sense and then um once I get those EOBs I can take care of these $50 payments we have that aren't just perfect.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] Absolutely.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Alright, so there wasn't anything else I could help you with?
[CUSTOMER][NEUTRAL] Um, do we have a reference number?
[AGENT][NEUTRAL] It would just be my first name, last initial, and today's date. Uh so my name is spelled [PII]
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][POSITIVE] Thank you very much for your help today.
[AGENT][POSITIVE] Of course, yeah, thanks for calling APL. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][POSITIVE] Thank you. Bye bye.