AccountId: 011433970860
ContactId: fed0f40e-5af4-47c2-8cbe-19fdfc99495a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 639830 ms
Total Talk Time (AGENT): 251766 ms
Total Talk Time (CUSTOMER): 255608 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/fed0f40e-5af4-47c2-8cbe-19fdfc99495a_20250109T23:36_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL this is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi. Uh, yes, I have a question about a claim.
[AGENT][POSITIVE] OK, I'm happy to check on a claim for you. Do you have a policy number?
[CUSTOMER][NEUTRAL] Um, yeah, and.
[CUSTOMER][NEUTRAL] 02216522.
[AGENT][NEUTRAL] Alright, thank you so much. Let me pull this up and are you the insured or are you calling from our provider's office?
[CUSTOMER][NEUTRAL] On the insured?
[AGENT][NEUTRAL] OK. Can I get your uh first name, last name, and date of birth, please?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] Thank you so much. And then I just need to verify please the address on file.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you so much. Was the claim, um, a claim for yourself or is it for somebody else on the policy?
[CUSTOMER][NEUTRAL] Um, for myself.
[AGENT][NEUTRAL] It was for yourself? OK.
[AGENT][NEUTRAL] All right, so I do show a claim that was reported, um, it's showing a reported date as of yesterday. This claim is still showing in progress at this time um it hasn't been completely processed yet.
[CUSTOMER][NEUTRAL] OK. Um, can I ask, I, I, I'm not, I don't remember what the benefit, how the benefit works. Um, it was, had a surgical procedure in December.
[CUSTOMER][NEUTRAL] I see that you already got something to anesthesia.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, what other benefits, uh, do I have for this procedure for, yeah, for the.
[CUSTOMER][NEUTRAL] Um, for the hospital out and the, you know, the rest of the bill.
[AGENT][NEUTRAL] Let's see what the.
[AGENT][NEUTRAL] So it looks like on your plan your outpatient benefit um is $200 per calendar day so it's only gonna pay on a maximum of an additional $200 for a certain date of service so like if the procedure was done on let's say [PII], then it would pay $200 on the [PII].
[AGENT][NEUTRAL] And then if you had any other sort of follow-up care, like if you're still in the hospital the next day, then the plan would pay another $200 for the following day. Does that make sense?
[CUSTOMER][NEUTRAL] Oh, OK, so there's no additional benefits for anything other than the events just a one time whoever bills first, I guess.
[AGENT][NEUTRAL] Yeah, not under the outpatient, it doesn't look like. Um, it looks like the anesthesiologist exhausted the $200 for the [PII]. Um, if there are any other claims for a different date, then of course, that would fall under a different calendar date. Uh, the only other benefits on the plan would be inpatient.
[AGENT][NEUTRAL] And inpatient is being in the hospital for, you know, any services as long as you're in the hospital for 18 hours or longer.
[CUSTOMER][NEUTRAL] OK, so there's, it's the maximum that you pay out of any benefit is 200.
[AGENT][NEUTRAL] For the outpatient benefit, yes, per calendar day, right? It's 200, that's the max.
[CUSTOMER][NEUTRAL] So there, there wouldn't be any additional benefits for a surgical procedure or anything like that. Just one time, 200, that's it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, all right, OK.
[AGENT][NEUTRAL] Did
[AGENT][NEUTRAL] Did you need me to check on anything else for you?
[CUSTOMER][NEUTRAL] Um, well, I think there was something on my son [PII] from, I believe it was [PII] or [PII] that
[CUSTOMER][NEUTRAL] Um, he went to the emergency room at [PII] State.
[CUSTOMER][NEUTRAL] Um, I know that my, at the, my, or at the time, his uh insurance didn't cover.
[CUSTOMER][NEUTRAL] Um, no, actually it's the same insurance. The insurance didn't cover out of state, his primary insurance, but it did cover emergency, it does cover emergency room visits.
[CUSTOMER][NEUTRAL] Um, however, that, I think that claim from the ER was was also denied.
[AGENT][NEUTRAL] Who was it under again?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. Um.
[AGENT][NEUTRAL] Do you remember the date of service or you just remember it was like in [PII]?
[CUSTOMER][NEUTRAL] Yeah, yeah, I'm looking for the page but I can't see it now but it was.
[CUSTOMER][NEUTRAL] Uh, I, I believe it was [PII].
[CUSTOMER][NEUTRAL] Ah
[CUSTOMER][NEUTRAL] I see no it's not doesn't appear to be here anymore.
[CUSTOMER][NEUTRAL] If it's this one
[CUSTOMER][NEUTRAL] this one from ACL.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] So there was a date of service under him for [PII]. It was OSU Emergency medicine.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah. Mhm.
[AGENT][NEUTRAL] So that claim was denied only because we needed the explanation of benefits from your primary.
[AGENT][NEUTRAL] So we just needed a claim um something showing what your primary insurance did pay, if anything.
[CUSTOMER][NEUTRAL] Um, it does not happen automatically, I mean.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] A insurance.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] With my primary insurance will pay.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Let's see, um.
[CUSTOMER][NEUTRAL] If I can, um.
[CUSTOMER][NEUTRAL] Uh, I've never had to provide that before. Uh.
[CUSTOMER][NEUTRAL] Yeah, let's see.
[CUSTOMER][NEUTRAL] Yeah, I've never had to provide that before. I don't know why.
[AGENT][NEUTRAL] Usually, if the provider's billing on your behalf, they will bill the uh primary first and then they bill us for anything remaining. Um, but yeah, anytime that a claim is submitted for this insurance because it's secondary, um, it's covering deductible, co-pay, or co-insurance that your primary doesn't.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] So, um, that's why we need explanation of benefits to show what the primary paid towards and what the residual amount due is.
[CUSTOMER][NEUTRAL] Um, I'm trying to figure out.
[CUSTOMER][NEUTRAL] Where would I find the claims my claims I guess my claim, or?
[AGENT][NEUTRAL] For your primary?
[CUSTOMER][NEUTRAL] Maybe this
[CUSTOMER][NEUTRAL] No, for, um,
[CUSTOMER][NEUTRAL] I'm trying to, right, I'm trying to figure out where my uh on my app for my primary.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] That where that would be, don't come in November, maybe it's here, hold on.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Would it be something
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] You mean if they have a mobile site or an app, you should be able to go in and look at um.
[AGENT][NEUTRAL] Any claims that have been filed.
[AGENT][NEUTRAL] And um you should be able to either print or download the explanation of benefits, or you should be able to contact them and just ask for that patient, you know, your son [PII] and that date of service.
[CUSTOMER][NEUTRAL] Oh here
[CUSTOMER][NEUTRAL] Yeah, I, I found it. How do I, uh.
[CUSTOMER][NEUTRAL] How do I get this to you? Um,
[AGENT][NEUTRAL] So if you have an option to download it on your computer, I would download it and then through our online service center you can upload the document um through there. Have you ever logged on to the online service center for us?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] In a while. OK. No, it's, it's been a while. I don't, I don't know that I have that password. OK. Um, yeah, I can't do that right now, but, so at this point, we've already paid.
[CUSTOMER][NEUTRAL] For this, um,
[CUSTOMER][NEUTRAL] How do I get at this point if you're not gonna pay them, right? If I send you, you'll pay it to us?
[AGENT][POSITIVE] Mhm. Correct.
[CUSTOMER][NEUTRAL] OK, all right. So I guess I have to figure out how to download this.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Claim approved, yeah, it was paid out in May.
[CUSTOMER][NEUTRAL] And I just have to go back. OK, uh, so I will um
[CUSTOMER][NEUTRAL] I will have to figure out how to download. OK, that's, that's OK. I'll I'll do that. OK, thank you.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. I hope you have a nice day.
[CUSTOMER][POSITIVE] You too. Thank you.
[AGENT][NEUTRAL] Bye-bye.