AccountId: 011433970860
ContactId: d5bb97a6-f0b5-4604-a456-4ae9331b10c6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 678359 ms
Total Talk Time (AGENT): 262464 ms
Total Talk Time (CUSTOMER): 345349 ms
Interruptions: 2
Overall Sentiment: AGENT=1.3, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/03/d5bb97a6-f0b5-4604-a456-4ae9331b10c6_20250403T16:52_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I help you?
[CUSTOMER][POSITIVE] Hey there um I actually just called you guys.
[CUSTOMER][NEUTRAL] Uh, about 30 minutes ago and, and have some questions, but I just spoke with um the hospital about my bill, and now I have some more questions. So I was just gonna see if you could help me with those.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] I'll be happy to assist you. May I have your name and the policy number?
[CUSTOMER][NEUTRAL] Sure, [PII], um, and the policy number is 02218541.
[AGENT][POSITIVE] Thank you, and [PII], may I have a good callback number for you?
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][NEUTRAL] Thank you. Can you verify your date of birth, your mailing address, and your email, please?
[CUSTOMER][NEUTRAL] OK, this is for my daughter [PII], um, and her date of birth is [PII], and the address is [PII].
[AGENT][NEUTRAL] And do you have an email address?
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Thank you for verifying that information. Please be advised that verification of coverage does not guarantee the payment of a claim. And how may I help you today?
[CUSTOMER][NEUTRAL] Sure, sure.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] OK, so I, my daughter went to the hospital on um in January and um I got a bill from them. I got one invoice for 2-1806 and
[CUSTOMER][NEUTRAL] That I just found out is a doctor's see. So,
[CUSTOMER][NEUTRAL] what I wanna know is I know that they are sending that to you to see if you will cover any of that. Do you know if that will be covered?
[AGENT][NEUTRAL] OK, so what was the date of service?
[CUSTOMER][NEUTRAL] Um, so it was.
[CUSTOMER][NEUTRAL] Gosh, why is it not shutting here?
[CUSTOMER][NEUTRAL] Sorry, let me get I've got it. Hold on.
[CUSTOMER][NEUTRAL] [PII] and I think the [PII].
[AGENT][NEUTRAL] [PII] an ER visit?
[CUSTOMER][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK, so it looks like this ER visit, let me get it pulled up.
[CUSTOMER][NEGATIVE] So I guess what I just found out is that there's a doctor's bill, and then there's a facility bill. But I haven't received the facility bill at all.
[AGENT][NEUTRAL] So it looks like the facility bill was Prisma Health. It looks like it processed the benefit amount of $4000 to the provider.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] This claim processed on [PII], looks like it maxed out the benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] 4000, there was also a $100 a $1000 deductible.
[AGENT][NEUTRAL] So anything that was received after that for [PII] will be denied as the max was met.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I can pretty much guarantee that that invoice for um let's see.
[CUSTOMER][NEGATIVE] 2 1806 will be denied by you guys.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Which you might already be showing that OK, so that will be denied by y'all.
[AGENT][NEUTRAL] Correct. And it doesn't look like we've received any of the doctor's bill. We did receive um
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Looks like some X-ray.
[CUSTOMER][NEUTRAL] Well, that's supposed to be the doctor's fee is the 21806.
[AGENT][NEUTRAL] OK, let me see.
[CUSTOMER][NEUTRAL] So the facility fee um for the 4,94143 you're saying so you guys applied the $4000 max right to that, so I should be left with the 941 43 then.
[AGENT][POSITIVE] Correct. That is correct.
[AGENT][POSITIVE] That is correct. Well, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, so the 21806 is denied. I'm probably gonna be left with that 941 43. And then what about.
[CUSTOMER][NEUTRAL] The 132.99. This is for, this is Prisma Health Medical Group. It's Department of Radiy. Was that denied?
[AGENT][NEUTRAL] Yes, there are 22 line items, um, this one processed under claim.
[CUSTOMER][NEUTRAL] Uh-huh. Yeah.
[AGENT][NEUTRAL] 357-477-3 it processed on 312 and denied as the max met for outpatient.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That was for 209.
[CUSTOMER][NEGATIVE] OK, all right, so that's denied.
[CUSTOMER][NEUTRAL] And you do because they're saying that they haven't heard from you for the 218061, but you're saying that's already been denied.
[AGENT][NEGATIVE] I'm not seeing a 21806 being received.
[CUSTOMER][NEGATIVE] Oh no.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] So the one for 368, it looks like it was the emergency room physician, that one came in and we denied asking for the major medical EOB.
[AGENT][NEUTRAL] Um, but that was the only one.
[CUSTOMER][NEUTRAL] Yeah, I don't have that one. I'm wondering if that's the same one and it was just oh wait 3368?
[AGENT][NEUTRAL] Yes, 368.
[CUSTOMER][NEUTRAL] OK, so what happened is the 368, so my primary paid.
[CUSTOMER][NEGATIVE] 149. 94 of that and now they're billing you guys for the remainder of 2-1806, but you're saying that that's gonna be denied that's already been denied.
[AGENT][POSITIVE] Correct. Correct. Well, no, no, no, ma'am.
[CUSTOMER][NEUTRAL] OK, OK, I assumed it would be.
[AGENT][NEUTRAL] It will be denied, but we are waiting for them to submit.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] You haven't done it yet, OK.
[AGENT][NEUTRAL] Yeah, so we denied it asking for the primary EOB.
[CUSTOMER][NEUTRAL] OK, alright.
[CUSTOMER][NEUTRAL] OK, all right. And then the last question I have is, OK, there's one from Clemson University Fire and EMS. It's the ambulance ride for [PII] that was also denied by you guys because the max had been met of 4000. Is that correct?
[AGENT][NEUTRAL] This one was processed and applied towards the deductible. It looks like on one line, 700 went to the deductible and the next line 13,650, went to the deductible.
[CUSTOMER][NEUTRAL] OK, so when you say that was applied, but I thought.
[CUSTOMER][NEUTRAL] I guess that confuses me because isn't there um.
[CUSTOMER][NEUTRAL] What is so what is our individual um deductible?
[AGENT][NEUTRAL] So under this plan, there is an outpatient $1000 deductible.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then the benefit amount allows 4000.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's same for inpatients.
[CUSTOMER][NEUTRAL] OK, so which one does this fall under then? Would that go?
[AGENT][NEUTRAL] It applied to the deductible for the emergency room because it was the first bill that had all the information needed to process. So that claim process applied to the deductible. So it looks like the benefit amount should have been 83,650.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For the ambulance. Is that correct?
[CUSTOMER][NEUTRAL] Yeah, that's what I'm showing that I owe though.
[AGENT][NEUTRAL] Yes, so that 8:36 was applied to the deductible and then the next claim.
[CUSTOMER][NEUTRAL] OK, of $1000 right?
[AGENT][NEUTRAL] Right. The next claim that came in was for the actual facility and it applied the
[AGENT][NEUTRAL] $4000 to the benefit after the 163.50 went to the deductible, which made the $1000.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so meaning we've met that $1000 deductible, correct?
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] But what does that mean? Because the last, the last person I said to you.
[CUSTOMER][NEUTRAL] Uh, or spoke to said that we hadn't met the, well, we have met the $4000 deductible.
[AGENT][NEUTRAL] No, it's not a.
[CUSTOMER][NEUTRAL] So what happens if you
[AGENT][NEUTRAL] It's not 4000, it's 1000 deductible. The benefit is 4000.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] The benefits, so, OK, that's the max. OK, so.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I don't know why that's so confusing. OK, so that 8 8:36.50 went towards that deductible, um.
[AGENT][NEUTRAL] Did you
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] But because we've met the $4000 max, even if we have another claim, it's not gonna be paid because we've met that $4000 max.
[AGENT][POSITIVE] For the year, that is correct.
[CUSTOMER][NEUTRAL] And I think
[CUSTOMER][NEUTRAL] Yeah, OK, and what is it?
[CUSTOMER][NEUTRAL] Do you know when my year starts?
[AGENT][NEUTRAL] It's a calendar year.
[CUSTOMER][NEUTRAL] OK, does it start in January?
[AGENT][NEUTRAL] Yes, ma'am. January [PII] December.
[CUSTOMER][NEUTRAL] Start in January.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And she is the only one who's met their max.
[CUSTOMER][NEUTRAL] OK. All right.
[CUSTOMER][NEUTRAL] Yeah, yeah, OK.
[CUSTOMER][NEUTRAL] OK, alright, that's making more sense now, so I can probably expect to see a facility fee for that 941-43 since you guys um.
[CUSTOMER][NEUTRAL] We'll only pay the 4000, correct?
[AGENT][NEUTRAL] Correct. [PII], did you register your account online?
[CUSTOMER][NEUTRAL] Um, I don't think so.
[AGENT][NEUTRAL] If cause if you register online, you can see every claim that's been submitted for the entire family. Yes, ma'am. It'll show you everything.
[CUSTOMER][NEUTRAL] Everything.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, I need to do that. I'll probably do that, but it helps talking to someone because I don't understand any of this stuff, so I appreciate your help.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] Yeah, and you can call us anytime. You're welcome. You can call us anytime, [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, thank you so much for your help.
[AGENT][POSITIVE] [PII], you're so welcome and thank you for calling American Public Life. Have a great rest of your day.
[CUSTOMER][POSITIVE] All right you as well. Take care bye bye.
[AGENT][POSITIVE] Thank you. Bye bye.