AccountId: 011433970860
ContactId: c1595591-7085-49b8-afaa-393663a48ace
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 497589 ms
Total Talk Time (AGENT): 239952 ms
Total Talk Time (CUSTOMER): 148357 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/14/c1595591-7085-49b8-afaa-393663a48ace_20250514T12:50_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], it's [PII] at UPMC Pinnacle. How are you today?
[AGENT][POSITIVE] I'm doing good. How are you doing?
[CUSTOMER][NEUTRAL] Uh, not bad, little rainy here, but we need it, so.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I'm taking
[CUSTOMER][NEUTRAL] I have a really bizarre question on an EOB for a patient.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, either, either having a severe senior moment or something got discombobulated somewhere.
[AGENT][NEUTRAL] OK. Well, I can help you with your um question about the EOB. May I have a good contact number in case we're disconnected and then the policy number?
[CUSTOMER][NEUTRAL] Yes, direct dial [PII].
[CUSTOMER][NEUTRAL] Policy ID is 02.
[CUSTOMER][NEUTRAL] 595-576
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure can. It is for [PII]. His date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the claim number um on the EOB?
[CUSTOMER][NEUTRAL] Yes, it is 359-598-4.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK. And then what's the um what's the question that you have?
[CUSTOMER][NEUTRAL] Um, we build this as an inpatient bill.
[CUSTOMER][NEUTRAL] With room and board days and all the ancillary charges.
[CUSTOMER][NEUTRAL] Um, so the charges total $37,198.60.
[CUSTOMER][NEUTRAL] But the EOB is.
[CUSTOMER][NEGATIVE] 5 lines at $900 each, so nothing's matching up.
[AGENT][NEUTRAL] OK. Um, do you mind if I place you on just a brief hold so I can take a look at the claim and the benefits and how it was paid out, um, to see what's going on. OK, hold on one moment, OK? You're welcome.
[CUSTOMER][POSITIVE] Sure, that'd be great.
[CUSTOMER][POSITIVE] Thanks so much.
[AGENT][NEUTRAL] Hold on.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] Oh, my nose is stuffy.
[AGENT][NEUTRAL] OK. Let's start here. Well,
[AGENT][NEUTRAL] It's HI, so let's see if the policy service up there.
[AGENT][NEUTRAL] OK, no, oh wait, you know what, hold on, let me do this.
[AGENT][NEUTRAL] Maybe it's C.
[AGENT][NEUTRAL] Oh yes, E and DTP.
[AGENT][NEUTRAL] What
[AGENT][NEUTRAL] Oops.
[AGENT][NEUTRAL] Alright, so hospital admission benefit is 500.
[AGENT][NEUTRAL] I pressed you are.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] $2550.
[AGENT][NEUTRAL] Per day max 30.
[AGENT][NEUTRAL] I see why.
[AGENT][NEUTRAL] RSER is 52 C Y.
[AGENT][NEUTRAL] And diagnostic testing is 101.
[AGENT][NEUTRAL] And let
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] How did they pay?
[AGENT][POSITIVE] Now that I have the benefits.
[AGENT][POSITIVE] I really mentioned we gave it a 5 consignment.
[AGENT][NEUTRAL] She was in there 5 days.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] We gave her a 250, 51 I mean 2, so we use 1.
[AGENT][NEUTRAL] OK, so let's talk about it.
[AGENT][NEUTRAL] Hello [PII].
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Hey, thank you so much for holding. I apologize for that wait. OK, so I went through the claim and how it was paid, so
[CUSTOMER][NEUTRAL] I'm here
[AGENT][NEUTRAL] This policy is a hospital indemnity policy, so it's a limited medical policy. So,
[AGENT][NEUTRAL] Oh I do see the total charges, but the policy can only pay up to its max. So, for example, the hospital admission, um, which had a charge of $37,198.60 the policy only pays $500.01 time per calendar year, so the $500 was applied to that.
[AGENT][NEUTRAL] And then the room and board or the hospital confinement.
[AGENT][NEUTRAL] The policy pays $50 per day with a max of 30 days per calendar year and um
[AGENT][NEUTRAL] They were there for 5 days, so that's why it was paid 250.
[AGENT][NEUTRAL] Um, the emergency room benefit is $50.02 times per calendar year, so $50 was applied to the ER charge.
[AGENT][NEUTRAL] Um, and then the diagnostic testing.
[AGENT][NEUTRAL] Pays $100.01 time per calendar year, so the $100 was applied to that um charge.
[CUSTOMER][NEUTRAL] OK, can we back up to the room and board, you said 50 per day.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] To a max of
[AGENT][NEUTRAL] 50 per day with a max of 30 days per calendar year.
[CUSTOMER][NEUTRAL] 30 per year, OK.
[CUSTOMER][NEUTRAL] My headset faded out because they're doing construction across the street from us, so sometimes all that noise or they, they bump, yeah, they bump the line cause it's like cranes and trucks and pipes and stuff, so every now and then voices fade out so I apologize I.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You can't hear it.
[AGENT][NEUTRAL] OK. Oh, no, you're fine.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] It's no worries at all.
[CUSTOMER][NEUTRAL] OK, so then to make sure I understand with this $900 payment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The balance has been his responsibility.
[AGENT][NEUTRAL] So we don't determine patient responsibility because we're not the major, we're not a major medical insurance company, but it would just, it, it would be whatever you as the provider, you know, your policies are on outstanding balances.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alrighty. Is there a call reference number?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name in today's date, and again, I'm [PII], first initial to my last name is [PII].
[CUSTOMER][POSITIVE] All right, great. Thanks so much for your help. I appreciate it.
[AGENT][POSITIVE] You're welcome, [PII]. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] That'll do it for now. Thank you.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Have a great day.
[CUSTOMER][POSITIVE] You as well. Thank you.
[AGENT][POSITIVE] You're welcome bye bye.