AccountId: 011433970860
ContactId: d0b982ff-449c-4dd9-a831-f2aebc901ce6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 380070 ms
Total Talk Time (AGENT): 123622 ms
Total Talk Time (CUSTOMER): 120653 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/02/d0b982ff-449c-4dd9-a831-f2aebc901ce6_20250602T14:49_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling to um review this claim. Um, I just wanna know how this claim was paid.
[AGENT][NEUTRAL] OK, let's take a look. Do you have the patient's policy number?
[CUSTOMER][NEUTRAL] I have um 02557753.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let's see if it.
[AGENT][NEUTRAL] And [PII], do you have a good callback number just in case we're disconnected?
[CUSTOMER][NEUTRAL] Uh yes, my callback number is [PII].
[AGENT][POSITIVE] Thank you so much. What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Um, that is, date of birth is
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] And what was the date of service?
[CUSTOMER][NEUTRAL] Uh, the data service is
[CUSTOMER][NEUTRAL] Let's see, is [PII].
[AGENT][NEUTRAL] Alright, and then what was the billed amount?
[CUSTOMER][NEUTRAL] Uh, the bill amount is for um 1,719.
[AGENT][NEUTRAL] Alright, so looks like on this claim there was a benefit payment sent to the provider and it was in the amount of $75.
[CUSTOMER][NEUTRAL] Yeah. And uh we did receive that payment, but
[CUSTOMER][NEUTRAL] I was wondering how the claim was payable line items because on the EOB it just says $75 but doesn't give me an EOB like if there's anything that was applied to the patient.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, OK, let me pull, let me pull up the EOB because I can send that to you. Give me just a moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so do you guys just have a line item that states basically that this is the max benefit payable for the date of service?
[CUSTOMER][NEUTRAL] Um, let's see. Um, yeah, because we, patient came through the ER and had other services done, um, radiology, um, pharmacy, and the ER, um, but yeah, we do need like a breakdown how this claim was processed and paid.
[AGENT][NEUTRAL] So this was just the procedure for the ER. There was nothing else submitted on this, it looks like.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Really?
[AGENT][NEUTRAL] Yeah. So when you see under the outpatient sickness benefit, and then it says ER, there was no other sort of like radiology or any of that submitted on this particular claim.
[CUSTOMER][NEUTRAL] That's weird because we just submitted the claim like the
[CUSTOMER][NEUTRAL] The, the bill.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Yeah, no, because, so the patient has like a limited benefit plan. It's not a major medical. It's what they call like a hospital indemnity plan. So it just pays a set amount depending upon what they're being seen or treated for. So like under this plan, like if they visit the ER it's a $75 benefit period, you know.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh, he's just gonna allow $75 per visit, right, for the ER visit?
[AGENT][NEGATIVE] Right, yeah, it's, yeah, it's not gonna pay like a higher percentage or, or anything like that. It's basically just that set amount, it doesn't pay anything more.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I don't know if maybe that's helpful.
[CUSTOMER][NEUTRAL] Yeah, because if you guys are only gonna pay the $75 because the patient has a um limited plan, then the rest will be the patient's responsibility.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and your name is again?
[AGENT][NEUTRAL] My name is [PII]. That's [PII]
[CUSTOMER][POSITIVE] OK. [PII], thank you so much for your help.
[AGENT][POSITIVE] You're welcome. I hope you have a good rest of your day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.