AccountId: 011433970860
ContactId: e490dbb4-e91b-40c1-9071-2c584d0d1827
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1038290 ms
Total Talk Time (AGENT): 543335 ms
Total Talk Time (CUSTOMER): 307672 ms
Interruptions: 3
Overall Sentiment: AGENT=0.7, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/03/e490dbb4-e91b-40c1-9071-2c584d0d1827_20250403T15:46_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][NEGATIVE] Hey, [PII]. Uh, my name is [PII], and I am calling about, um, a claim that it's a, it's a bill that I got my daughter had to go to the emergency room and, and took an ambulance. And I called the company and they said that you guys are not responding.
[CUSTOMER][NEUTRAL] To what they sent you, so I was just kinda calling to see what might be going on. Mhm.
[AGENT][NEUTRAL] See what's going on.
[AGENT][NEUTRAL] OK. Well, I can definitely look into it for you and provide you with an update and see what's going on with the claim. And [PII], may I have a good contact number in case we're disconnected and then um the policy number?
[CUSTOMER][NEUTRAL] Sure. Um [PII].
[CUSTOMER][NEUTRAL] 4553055
[AGENT][POSITIVE] Thank you for that.
[AGENT][NEUTRAL] And your policy number whenever you're ready.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Alright, 02218541.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And I have the policy here. I just need you to verify your date of birth and the mailing address on file.
[CUSTOMER][NEUTRAL] OK, my date of birth is [PII], and the mailing address is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And um would this be for [PII] or [PII]?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] [PII], OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hold on one moment, let me go to her.
[CUSTOMER][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK, and what is the name of the provider?
[CUSTOMER][NEUTRAL] OK, so it's Clemson University Fire and EMS.
[AGENT][NEUTRAL] I and ENS OK.
[AGENT][NEUTRAL] Hold on 1 2nd.
[CUSTOMER][NEUTRAL] I've actually got a couple that I wanna ask you about.
[AGENT][NEUTRAL] OK, um, so just looking through the, hold on one moment.
[AGENT][NEUTRAL] 1234. We've only processed 5 claims for her, um, but I don't see anything from Clemson 5.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So then my next question would be where are they sending it to? What are they mailing it? Are they faxing it?
[AGENT][NEUTRAL] And then where cause
[CUSTOMER][NEUTRAL] You know, that's the.
[CUSTOMER][NEUTRAL] Yeah, so you haven't gotten anything from them.
[AGENT][NEUTRAL] Because
[AGENT][NEUTRAL] Hold on one second. Is this from January?
[CUSTOMER][NEUTRAL] Yeah sure.
[CUSTOMER][NEUTRAL] Um, yeah.
[AGENT][NEUTRAL] OK, here goes one.
[AGENT][NEGATIVE] What is this? I mean, they should have received the explanation of benefits. I can send it to them if they need a copy. I just to say we haven't responded.
[AGENT][NEUTRAL] But you have an explanation of benefits.
[CUSTOMER][NEGATIVE] Yeah they're saying you haven't responded.
[AGENT][NEUTRAL] Right, so that's the only, let me just make sure if this is the only one. We have one from [PII] that claim, um, I'm getting that claim information now.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what's that claim number?
[AGENT][NEUTRAL] Hold on one moment, it's all different spaces.
[CUSTOMER][POSITIVE] Yeah, sure, take your time.
[AGENT][NEUTRAL] Alright, so that was the first one. Are there any more? I think these two said Prisma.
[CUSTOMER][NEUTRAL] Yeah, there, there should be 2 from PRSA and then 1 from Clemson University Fire and EMS.
[AGENT][NEUTRAL] OK, so that, so yes, we only received one from them. We received it on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, that's claim number 356-8794.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, which, which one is that from Prisma?
[AGENT][NEUTRAL] No, this is Clemson.
[CUSTOMER][NEUTRAL] Oh it is OK.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, so you did receive it from them.
[AGENT][NEUTRAL] Mhm. Um, so, and we sent the explanation of benefits back to them on [PII].
[AGENT][NEUTRAL] Um, so,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I don't want to say the claim was denied because it wasn't denied, it was just applied to her deductible.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] So what is the deductible?
[AGENT][NEUTRAL] Hold on 1 2nd.
[AGENT][NEUTRAL] So the outpatient deductible for accident or sickness is $1000.
[CUSTOMER][NEUTRAL] OK, so you just applied it to that and there's nothing else we haven't, is it an individual deductible?
[CUSTOMER][NEUTRAL] I don't know if that's a stupid question or not, is it?
[AGENT][NEUTRAL] Let me see if that's, no, it's not, that's not, no, it's not a, that's not. No, no, I'm saying that's not a crazy question. I'm gonna look it up for you though. Hold on.
[CUSTOMER][NEUTRAL] It's not so that's for the family, OK.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Because sometimes it is for just one for everybody and then sometimes it's each person.
[AGENT][NEUTRAL] So let me double check.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] But now if they do need a copy of the explanation of benefits, we can resend it to them. I just didn't want you to feel like we were really not answering something.
[CUSTOMER][NEUTRAL] Right, not, yeah, yeah.
[AGENT][NEUTRAL] OK, let me see the certificate. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm just pulling up the um policy benefits so I can see if it's per person or
[AGENT][NEUTRAL] Um, for the family.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, $1000 deductible per covered person per calendar year.
[CUSTOMER][NEUTRAL] So it's per person.
[CUSTOMER][NEUTRAL] OK, so she, there were no other claims and then so she hadn't met that deductible so therefore you guys aren't, you wouldn't be covering any of that, correct?
[AGENT][NEUTRAL] Correct. Now, one of the um one of the claims from Prisma.
[AGENT][NEUTRAL] So hold on. So that one came in on [PII] from [PII], and then we have one coming in [PII] from Prisma. Now that one was paid out $4000.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you know if that was for.
[CUSTOMER][NEUTRAL] The so there I got 2 from Prisma Health. One was from the hospital itself and then one was from the radiology department.
[AGENT][NEUTRAL] Does the radiology one say upstate, because that's
[CUSTOMER][NEUTRAL] Do you
[CUSTOMER][NEUTRAL] No, neither one said.
[AGENT][NEUTRAL] Let me see because they both say personal but one.
[AGENT][NEUTRAL] OK, let me see if there's another way I can try to decipher. Um, cause they're all the same, yeah, they're all the [PII]. 1 says Prisma Health Medical Group, the other says Prisma Health Upstate. So I'm trying to see how I can, let me look and see if I can see the code.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, so this one says Prisma Health Medical Group.
[AGENT][NEUTRAL] OK, hold on, let me go back to that one.
[CUSTOMER][NEUTRAL] And that
[AGENT][NEUTRAL] OK, so I'm where you are now. And then what's wrong, what um what questions did you have about that one?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so did, so did you, were you guys able to pay any of that because the deductible, um, it should have been met right by that point for her?
[AGENT][NEUTRAL] This one is the same, um, benefits have been applied to the deductible. So the only
[AGENT][NEUTRAL] So the only um
[AGENT][NEUTRAL] The only other one, wait, let me go back to the second Prisma.
[AGENT][NEUTRAL] Wait,
[AGENT][NEUTRAL] Hold on one second. You said you have 2 from Prisma too though, right?
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] I'm trying to see, go ahead.
[CUSTOMER][NEUTRAL] I do. One.
[CUSTOMER][NEUTRAL] One is from the hospital and then this one that I was talking to you about the Prisma Health Medical Group is from the Department of Radilogy specifically.
[AGENT][NEUTRAL] The reason I'm hesitating is because if we paid 4000 on this claim,
[CUSTOMER][NEUTRAL] Right then why is the other one not?
[AGENT][NEUTRAL] Is the second one. Why is the 2nd 1 saying deductible? OK, so for this one, this is what I think I should do. I'm going to reach out to claims and get an examiner on the line just because they're the ones to process it to see if maybe there's a piece I'm missing. But to me, that's what it looks like that first one from Prisma, we oh well, the Prisma Health Upstate, that one we did pay $41,000 on, which makes me think the deductible would have been met.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Had been
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So, um, I'm just gonna get an examiner to, yeah, to see, um,
[CUSTOMER][NEUTRAL] Which makes sense
[AGENT][NEUTRAL] And explain, you know, just go over with you more.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, yeah, that would be great.
[AGENT][NEUTRAL] OK. Well, before I do that, Mrs. [PII], was there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, I think that's good. I appreciate your help.
[AGENT][POSITIVE] Well, you're very welcome and thanks for calling APL. Hold on one moment while I get a representative for you, OK?
[CUSTOMER][POSITIVE] OK sounds good thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Referring
[AGENT][POSITIVE] OK thank you.
[CUSTOMER][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you?
[CUSTOMER][NEUTRAL] I'm fine thanks how are you?
[AGENT][POSITIVE] I'm doing good. Um, I have a
[AGENT][NEUTRAL] Insured on the other line that needs to speak with um someone. Can you look at this policy with me?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Uh, it's policy number 221-854-1 for part 4.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So the, the last 3 claims that we processed for her, uh, really 4.
[AGENT][NEUTRAL] Um, starting [PII] up.
[AGENT][NEGATIVE] So the [PII] and the [PII] were denied um.
[AGENT][NEUTRAL] But then she's asking if the deductible.
[AGENT][NEUTRAL] She wants to talk about the deductible. I told her that the deductible was met, but she wants to know why the other um claim, hold on one second, my line is just flicking. I'm sorry.
[CUSTOMER][NEUTRAL] You're fine.
[AGENT][NEGATIVE] She just wants more clarity about her claims and applied to deductible versus pay because the 4th, the one received on [PII] was paid $4000 but then the one after that was denied and I'm trying to get to.
[AGENT][NEUTRAL] My REMRI and everything is just blinking.
[CUSTOMER][NEUTRAL] OK, give me just a second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I can see.
[CUSTOMER][NEUTRAL] Just by looking at it, the emergency room, like there's no deductible for those benefits, so that's why that one was paid.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So let me see.
[AGENT][NEUTRAL] I see.
[AGENT][NEUTRAL] I don't need to transfer. It just stopped blinking and I see what the outpatient, it says outpatient benefit for the calendar year met, so that's why that second one, she had already the 4000 maxed it out when we paid the ER. OK, I just couldn't get to it.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] And I'm like, hold on, OK, um, I can handle it. Thank you though.
[CUSTOMER][NEUTRAL] OK. Are you sure?
[AGENT][POSITIVE] Yes, I'm good.
[CUSTOMER][NEUTRAL] OK, yeah, well, let me know if you have any other questions.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] All right, thank you, [PII].
[CUSTOMER][NEUTRAL] I think.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][POSITIVE] You're welcome bye bye.
[AGENT][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, thanks for holding. While I was waiting for the claims examiner, I saw the difference. This last claim that was processed on [PII], it's denied because the outpatient max was met, not the deductible. The codes are DM 360 and 306. Um, so they're similar, but this last one, it wasn't denied because of the, it was applied to the deductible. When we paid the $4000 that fulfilled the deductible as well.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, this claim was then denied because we paid that $4000 which maxed out the outpatient benefit for that year.
[CUSTOMER][NEUTRAL] Oh, OK, so you're saying, OK, so because you pay the 4000 for the 1, then the other two, you're not gonna pay out because she's already met that that amount.
[AGENT][NEUTRAL] Well, so that first one from [PII], that one was denied because at the time, so that one was denied because, well, it was denied but applied to the deductible. Then the first one came in from that uh Prisma Health Upstate, that's where the $1000 deductible was met and we paid out the $4000 which is your calendar year max.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] So then when that 3rd claim came in, we had already paid that 4 to the other one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Before.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] OK, so the one, OK, so the one from the $4000 like I still have a bill for them for 218, um, does that mean you've covered all of that or I guess I'm confused about that.
[AGENT][NEUTRAL] So they billed for $4,941.43 but your max is $4000. So we could all we could apply to that is the $4000. So that extra $941.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Since we're not like, you know, the, the primary or major, we don't determine the patient responsibility, we just apply and then if there's a remaining balance, they'll see that there and, you know, different providers have different policies, so they could then bill you, write it off. It depends on what, how that provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Handles their billing.
[CUSTOMER][NEUTRAL] OK, so, so, so each person has a $4000 max is what you're saying.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so that was gobbled up by that bill, so the other two are gonna be denied because that's already been met for the year.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] All right, so the one from the radiology department from Prisma Health Medical Group, I mean, are you showing that as denied as well?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] So yes, that one was actually denied because the outpatient max had been met.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, alright.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, so that makes sense. So that's our max per person is $4000 a year.
[AGENT][NEUTRAL] Yes, ma'am. And you have that for outpatient and inpatient. So, hopefully, you never have to use inpatient and be admitted. But if you do, you do have the 4000 there.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, alright, well that makes sense so you guys use that up for that one and then the other two were denied, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Alright well that answers my question.
[AGENT][NEUTRAL] All
[AGENT][POSITIVE] Well, I'm glad I could assist you, Ms. [PII]. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, but I really appreciate your help.
[AGENT][POSITIVE] Well, you're very welcome and thanks so much for calling APL. I hope you have a great day.
[CUSTOMER][POSITIVE] OK thanks you too.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.