AccountId: 011433970860
ContactId: fecb3fa5-1419-4ddd-ae3f-617dfaf73551
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 506429 ms
Total Talk Time (AGENT): 256668 ms
Total Talk Time (CUSTOMER): 213280 ms
Interruptions: 2
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/fecb3fa5-1419-4ddd-ae3f-617dfaf73551_20250225T15:11_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] I'm sorry, who am I speaking with?
[AGENT][NEUTRAL] This is [PII] with APL.
[CUSTOMER][NEUTRAL] Uh, so, how are you? My name is [PII]. I'm with Fortune Insurance. How are you?
[AGENT][POSITIVE] I'm good, thank you. How about you, Mr. [PII]?
[CUSTOMER][NEUTRAL] I'm doing well, always better on Friday at [PII], but so far trying to get to it.
[AGENT][POSITIVE] Yes, definitely.
[CUSTOMER][NEUTRAL] There you go.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, uh, I'm calling, um, I'm calling regarding one of our clients, um, I have one of the client's employees who, uh, recently had a child, I believe, and I got all these APL, um, uh, EOBs, and I'm just trying to figure out because the client's so confused and I'm, I'm at the point where I'm picking up where someone else left off, so I'm not too sure what's going on.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Now, uh, the employee's name is, I'll tell you who the employee's name is. I have all her information. I'm on the portal. Her name is your employee [PII]. Last name is [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you have a policy number, [PII]?
[CUSTOMER][NEUTRAL] Yes, I do. Policy number is 02273057.
[AGENT][NEUTRAL] OK, let me have a callback number just in case we get disconnected.
[CUSTOMER][NEUTRAL] My phone number is [PII].
[CUSTOMER][NEUTRAL] And then with Fortune Insurance we're the agent of record for this group.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Asian. OK, that was gonna be my next question. OK, one moment.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Do you have the date of birth of this member for security?
[CUSTOMER][NEUTRAL] Let's see, uh, let me see if I can find that on the portal because I'm on your portal. Let me see.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 2.
[CUSTOMER][NEUTRAL] C
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Let me see something here.
[CUSTOMER][NEUTRAL] Just bear with me.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I have.
[CUSTOMER][NEUTRAL] Oh, it doesn't say her I can give you her social.
[AGENT][NEUTRAL] The last 4 will be fine just for verification.
[CUSTOMER][NEUTRAL] That's what you go for social.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, perfect. Thank you. All right, here we go. OK, and so you're calling about the dependent for her, correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah she got um yeah I thought let me see what her email says because uh like I said I'm picking up where someone else left up uh she wants to find out about her claims because she says she's um.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because she says she wants to know what her refund's gonna be because I have, I have three EOBs from you guys, one for $355.46 1 for 1236.80, and another one for $1983 and I'm just wondering, is that something she's gonna get paid because she's asking about it if she can use to pay her balance. I'm like I'm not sure what's going on.
[CUSTOMER][NEUTRAL] I'm not sure what to do to her.
[AGENT][NEUTRAL] Hm, to her?
[AGENT][NEUTRAL] Mm, um, we have not received any claims directly from her. All the payments have gone directly to the provider of service for [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm. So all these payments are directly to the provider of service.
[CUSTOMER][NEUTRAL] OK, that's fine. uh, so I wanna know what she wants to know what her balance is gonna be what she has to put.
[AGENT][NEUTRAL] Mhm. Mhm.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Well, well, we, we're not gonna know how much your balance is gonna be, um, because what we do is, you know, we cover the co-payments, coinsurance and deductible up to the amount that the major medical decides to put to those, um, and basically, for what I see here, uh, kids's medical service but was paid fully on which it was the $1,236.80 we pay the full amount that was applied towards the deductible.
[AGENT][NEUTRAL] And let me see, uh, let me see if there's anything that is not fully paid.
[CUSTOMER][NEUTRAL] OK, let me see something. Alright, so you're saying, so you guys, you guys paid, uh, you got paid a total of how much? 22381 8066?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let me go back to that one because there there's several days of service, OK. So for the date of service, let's just put the date of service down. OK, for the date of service of [PII], we pay the full amount of $1,236.80.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, I'm sorry, the date again? 10 what?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] 103.
[CUSTOMER][NEUTRAL] 10 3 24 and you paid and you paid how much?
[AGENT][NEUTRAL] 24.
[AGENT][NEUTRAL] $1,236.80.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Which that was the full amount applied towards the deductible. That one was paid fully, OK, um, on the next one we have here, that's where some benefits are not paid fully, so let me check on those, OK. Um, for the date of service again of [PII].
[CUSTOMER][NEUTRAL] You paid the car
[CUSTOMER][POSITIVE] OK great.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] We also send the benefit for kids medical service, which is the same place of $2,424 which that one was paid fully.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] 2000 how much?
[AGENT][NEUTRAL] 2,424.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And then there's another charge for [PII].
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so that one was paid partially because the, the only remaining balance after we send the [PII] was $162.97.
[AGENT][NEUTRAL] And that's $162.97 was remaining.
[AGENT][NEUTRAL] Of the benefit.
[CUSTOMER][NEUTRAL] From the of the benefit, OK.
[AGENT][NEUTRAL] From the benefit. Mhm, yes, mhm. So.
[CUSTOMER][NEUTRAL] So, so, so all her benefits are maxed out, right?
[AGENT][NEUTRAL] The benefits are massed down, correct for the inpatient benefit because this was an inpatient. OK. So in in this point, um, there is a $209.76 we only pay 162.97 cents. There is a remaining balance of $46.79 for this one.
[AGENT][NEUTRAL] That's 76, I'm sorry, $46.79.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEGATIVE] OK. And then there's another charge that was not paid, that was denied completely because she already used her benefits of $1850.
[CUSTOMER][NEGATIVE] $1850 that's not covered.
[AGENT][NEGATIVE] That was not covered because at that point she already maxed all her benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm and then um let me see if I see anything else but it doesn't look like it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah so
[AGENT][NEUTRAL] That's basically all, so I guess that's the amount, yeah.
[CUSTOMER][NEUTRAL] OK, got you, because, because, yeah, because her max benefit, let me see something here. I'm just trying to see all the emails here because.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I said it's always a stem confusing. Uh, let me see what else I have to ask you what has a total of 4000 they've.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 400, 4000.
[CUSTOMER][NEUTRAL] OK, 193355 420 for the anesthesiologist 2381, that's the total paid balance is 1618.
[CUSTOMER][NEUTRAL] And then let me see then uhcologist OK.
[CUSTOMER][NEUTRAL] Alright, so amount to the hospital was 1983. got paid the full benefit, yep, that's true.
[CUSTOMER][NEUTRAL] Uh, 25,000 10% out of pocket 5500.
[CUSTOMER][NEUTRAL] OK, I owe you. She already met the deductible. She doesn't wanna pay another appointment until I pay them.
[CUSTOMER][POSITIVE] She said that she already met her $4000 you know what, she just hasn't reached the max out of pocket. That's what it is. OK, I think I figured this out. Thank you so much for your help and uh have a wonderful day, OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] Yes so, Mr. [PII], and thank you for calling ATL.
[CUSTOMER][POSITIVE] OK you got it bye bye.
[AGENT][NEUTRAL] Bye bye.