AccountId: 011433970860
ContactId: f7fef34c-32d9-4fef-8464-1b350b6d8b24
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 481630 ms
Total Talk Time (AGENT): 231980 ms
Total Talk Time (CUSTOMER): 208585 ms
Interruptions: 4
Overall Sentiment: AGENT=0.9, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/f7fef34c-32d9-4fef-8464-1b350b6d8b24_20250117T20:03_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How may I help you?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh, hi, my name is [PII] and I'm calling from a provider office, Providence Center Sinai Hospital.
[CUSTOMER][NEUTRAL] I have a question in one claim which has already been paid but I have a question on the paid amount uh.
[AGENT][POSITIVE] Sure, [PII], I can help you with that.
[CUSTOMER][NEUTRAL] What information it.
[AGENT][NEUTRAL] I can help you with that claim.
[CUSTOMER][NEUTRAL] Yeah, sorry, how do you spell your name?
[AGENT][NEUTRAL] Uh, [PII]
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Last initial [PII].
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] Thank you, [PII].
[AGENT][POSITIVE] You're welcome [PII]. Can I have your call back number in case we should get disconnected and I can call you back please.
[CUSTOMER][NEUTRAL] It's [PII] [PII].
[CUSTOMER][NEUTRAL] I get there.
[AGENT][NEUTRAL] [PII]?
[AGENT][NEUTRAL] OK, thank you. And may I please have the uh members policy certificate or ID number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh yeah, sure, the member ID is.
[CUSTOMER][NEUTRAL] 2175451
[CUSTOMER][NEUTRAL] Well.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] And just give me one moment to pull up that patient's policy.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Can I please have you verify the patient's name and their date of birth?
[CUSTOMER][NEUTRAL] Fishing is [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And [PII], do you have the claim number or do you wanna just give me the date of service and the amount on the claim?
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Uh, yeah, I do have the claim number. Just give me one moment.
[CUSTOMER][NEUTRAL] The claim number is 3543553.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 354-355-53
[AGENT][NEUTRAL] And it looks like it's for data service of uh [PII], I'm sorry, [PII], excuse me, to [PII], is that right?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So let me just pull up this claim image.
[AGENT][NEUTRAL] And you said you had a question about the amount paid, is that right?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, uh, we did receive the payment, and that is of 1500.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I just want to know one thing on what basis that the payment was made because we billed to you as a secondary and the primary has already paid and also.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Primary did paid $12,639.45 and.
[CUSTOMER][POSITIVE] There is patient liability which is uh can give you that OK.
[AGENT][NEUTRAL] Yeah, I see that here on the explanation of benefits.
[CUSTOMER][NEUTRAL] Patient was.
[CUSTOMER][NEUTRAL] 2100. Yes, so just want to know why we got the payment only um $1500 wherein the primary has left the patient liability of $5,173.55.
[AGENT][NEUTRAL] 55 cents, yes, I see that. OK, so, um, [PII], this policy is a supplemental limited benefit, uh, medical expense plan, so it is secondary to their major medical and it will cover co-insurance and or deductible amounts for services covered under the plan that's left from the primary insurance.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] However, um, this policy does have a benefit maximum of $1500 for the calendar year for inpatient services, so we paid that maximum allowed under this plan.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and is so is there any patient liability under that?
[AGENT][NEUTRAL] Well, we don't determine the patient responsibility due to this plan is not um it's not a it it it doesn't work it's more like a gap plan, but it does have limited benefits so we don't determine that patient liability. There's no write off or contractual adjustment made. We'll make that straight benefit payment which in this uh case was their benefit maximum of $1500.
[AGENT][NEUTRAL] So that patient balance um that would be up to the provider if they want to bill to the patient we don't determine that liability because there's no contractual adjustment we made our um benefit payment and that ends our um obligation for this uh claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So that is the maximum uh plan benefit.
[AGENT][POSITIVE] That's correct. Mhm.
[CUSTOMER][NEUTRAL] OK and.
[AGENT][NEUTRAL] Did you have any other questions, [PII]?
[CUSTOMER][NEUTRAL] So just wanted to know once I.
[CUSTOMER][NEUTRAL] Uh, yeah, just wanted to know one thing is.
[CUSTOMER][NEUTRAL] Uh, is there any, uh.
[CUSTOMER][NEUTRAL] Where where we can get that proper EOB we just get the copy of that check and then the only the first page of the EOB.
[AGENT][NEUTRAL] I could send the um duplicate EOB to you um however it's gonna contain that same information um that I just provided for you that that $1500 however, the second page will indicate to you that this is the maximum for the calendar year, um, that's allowed. Can I send it to you by fax?
[CUSTOMER][NEUTRAL] Uh, no, so if you disagree.
[AGENT][NEUTRAL] Do you have a fax number?
[CUSTOMER][NEUTRAL] Uh, no, I actually do not have the fax number, but OK, no problem then, so if.
[AGENT][NEUTRAL] Now you can get obtain it. I can give you the information uh we do have a web portal, um, a website portal where you can go and download the EOB. I can give you that information if you'd like.
[CUSTOMER][NEUTRAL] Is there any way where
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so you're gonna go to our uh secured uh portal website and it's the word secured [PII]
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And it's [PII], and that's all one word, [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And if you're not already signed up you'll sign up as a new user as a provider and all you'll need is the tax identification number and then you can use the patient account number and you should be able to pull up this explanation of benefits for that claim number 3543553.
[CUSTOMER][NEUTRAL] Alright, thank you, thank you and do you have any call reference number?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Certainly [PII] the call reference number you would use my name.
[AGENT][NEUTRAL] And today's date and again it's R O X Y last initial L like love.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you so much for your time and help, [PII]. You have a good day and happy weekend. Thank you.
[AGENT][POSITIVE] You too, you too, thank you so much, [PII] and I have thank you for calling APL and I hope you have a great weekend as well.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][POSITIVE] Yeah thank you bye bye now.
[AGENT][NEUTRAL] All right. Bye.