AccountId: 011433970860
ContactId: 00137461-6d06-419b-aa20-56849911cc03
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 598520 ms
Total Talk Time (AGENT): 292903 ms
Total Talk Time (CUSTOMER): 260849 ms
Interruptions: 3
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/30/00137461-6d06-419b-aa20-56849911cc03_20241230T21:04_UTC.wav
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[AGENT][NEUTRAL] Calling APL. My name is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hi [PII], it's [PII]. How are you doing today?
[AGENT][POSITIVE] I'm good how are you?
[CUSTOMER][POSITIVE] I'm doing well, thank you. [PII]'s yippee. Um, I have got a provider on the line.
[AGENT][POSITIVE] Happy [PII].
[CUSTOMER][NEUTRAL] That's going to need a little.
[CUSTOMER][NEUTRAL] Um, mm.
[CUSTOMER][NEUTRAL] How can I say it nicely? A little repetition of what I said.
[CUSTOMER][NEUTRAL] It's home policy number 1868865.
[CUSTOMER][NEUTRAL] And it's regarding claim number.
[CUSTOMER][NEUTRAL] 351
[CUSTOMER][NEUTRAL] 22
[CUSTOMER][NEUTRAL] 99.
[CUSTOMER][NEGATIVE] She was trying to explain that the 99214 is not covered. She's saying, but she does have the office treatment rider. We went over that and by the, you know, nothing applied in the EOB and yada yada, but she's not understanding why the 99214 is not covered if they are an outpatient facility, we went over the fact that the place of service is an 11, but she's still not understanding why it's not covered. Can you help her?
[AGENT][NEUTRAL] Yeah, it is what it is and I'm gonna tell it to her. I mean, that we can't rewrite the policy, but, but one thing about it, even just recently, we don't even pay it for um place of service 22. So it is.
[CUSTOMER][NEUTRAL] And her
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEGATIVE] And I was trying to explain to her, but she's like, I don't understand why it's not covered.
[AGENT][NEUTRAL] OK, I'll let her know. It's in the policy.
[CUSTOMER][NEUTRAL] Anyway, her name is, her name is [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And your callback number is not you want her callback number real quick?
[AGENT][POSITIVE] I'm ready.
[AGENT][NEUTRAL] Oh yeah, I'm sorry, I forgot about that.
[CUSTOMER][POSITIVE] Not a problem. I got you. Callback number is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] And let me get her on the line. I appreciate you, [PII]. You have a great day.
[AGENT][POSITIVE] Thank you. You too.
[CUSTOMER][POSITIVE] Thank you. One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] [PII], thank you for your patience. I have [PII] on the line. She's going to assist you further and have a wonderful day.
[AGENT][NEUTRAL] Hi.
[CUSTOMER][POSITIVE] Awesome thank you. Thank you bye bye.
[AGENT][NEUTRAL] Hi, this is [PII]. I understand you had a question in regards to a claim denial.
[CUSTOMER][NEUTRAL] Yes, um, so this station is double covered. Um, they do have Blue Cross Blue Shield as primary, and then of course they have American Public Life as secondary. Uh, we did receive payment from primary. We did, uh, send over the claim to secondary. I did, um, call it in just to see because we hadn't received any EOB or anything towards this claim. So I did just wanna get an update on it, and the lady that I just spoke to did specify that, um, the CPT code 99214 was not covered, um.
[CUSTOMER][NEUTRAL] Because it was a non-covered charge, so I did just wanna get a little bit more clarification to that as, uh, to, you know, why would that be if it is an office visit and she also did tell me that outpatient office visits are covered, so I was just a little confused.
[AGENT][NEUTRAL] OK, so the policy does not cover for the um.
[AGENT][NEUTRAL] The charges associated with the physician's charges, that co-pay that's associate associated with the physician's charges, we don't cover that. We only cover any treatment or procedures at the visit.
[CUSTOMER][NEUTRAL] OK, so then what you guys don't cover would just basically be the co-pay of the office visit.
[AGENT][NEUTRAL] Right. Any, anything else as long as there was patient responsibility applied to it like deductible, co-pay, co-insurance, any other um charges at the visit, we would cover, but not the co-pay associated with the physician's charges.
[CUSTOMER][NEUTRAL] Or
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] Mm, OK, see that's where I get confused, because right now, you stated that you guys do cover co-pays, deductibles, or any other services.
[CUSTOMER][NEUTRAL] But then
[CUSTOMER][NEUTRAL] You're saying no. So that's why I'm, I'm confused.
[CUSTOMER][NEUTRAL] Because this is a co-pay from their insurance.
[AGENT][NEUTRAL] For treatment and procedures, any, any patient responsibility.
[AGENT][NEUTRAL] Any patient responsibility that's applied to any treatment or procedures at an office visit.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, which would be this one because there was a $10 co-pay.
[AGENT][NEUTRAL] 99214 is not a treatment or a procedure. It's the it's the physician's charges.
[AGENT][NEUTRAL] That's what the physician charged to see her, correct? Is that not what 99214 is? Let me look it up one moment.
[CUSTOMER][NEUTRAL] That's an that's an established patient level 4 office visit, yes.
[AGENT][NEUTRAL] OK. So that's the charge that the doc, that's the doctor's charges for you seeing him, whether he does anything or not. That's just the
[AGENT][NEUTRAL] And that is always applied to their co-pay.
[CUSTOMER][NEUTRAL] Yeah, but that, that comes from, that's not from the doctor itself. That comes from the insurance that the patient has, which is Blue Cross Blue Shield. Their co-pay with the insurance, their patient responsibility is $10.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, but when you apply that $10 it's always to the 99214, correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, so that, that charge is associated with their co-pay for the visit and that is not covered.
[CUSTOMER][NEUTRAL] OK. And so what is covered is what exactly?
[AGENT][NEUTRAL] Anything else that's treatment or procedure related. So anything outside of that 9921499204.
[AGENT][NEUTRAL] And all of the associated physician charges, those are not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Just to clarify.
[CUSTOMER][NEUTRAL] Right now, when you stated that you guys do take responsibility or cover, pay anything that is towards patient deductible or co-pay.
[CUSTOMER][NEUTRAL] Then why did, why is it now not an option?
[CUSTOMER][NEUTRAL] Like, what different, like, what makes it different, in other words?
[AGENT][NEUTRAL] You're stuck on the word co-pay. You're, you're stuck on the word co-pay. The focus is, is this a treatment at this office visit? Are you, is this treatment? Is this charge for treatment? Is this charge for a procedure? If the answer is yes, then yes, that is covered. Is this charge associated with the uh physician's charges?
[AGENT][NEGATIVE] Or the evaluation charges, then the answer is no.
[AGENT][NEUTRAL] I've seen cases where normally they take the procedures and um they apply it to deductible or co-insurance, but I have seen instances where claims come through and there was a procedure that applied to the co-pay, but because it was a procedure code for a procedure in treatment, we paid it.
[AGENT][NEUTRAL] So I don't wanna tell you, no, we don't pay any co-pays. I'm saying we don't pay anything associated with that procedure code, whether it's 99214, 99204, 99219. It's a lot of other ones I can't remember. So that's uh how I need you to think about it in terms of, don't be stuck on the word co-pay. Be stuck on is this treatment? Is this a procedure? Green light. Is this the physician's charges, red light.
[CUSTOMER][NEUTRAL] Got you. OK, so on the claim you're able to see the ICD tech code, correct?
[AGENT][NEUTRAL] Yep
[CUSTOMER][NEUTRAL] OK. Uh, based off of those ICD 10 codes, or sorry, the codes, what would you say is the services that were provided? Wouldn't that be treatment for this patient because the patient is pregnant?
[CUSTOMER][NEUTRAL] And they are getting seen for their pregnancy.
[AGENT][NEUTRAL] The ICD 10 codes or the, the diagnosis codes.
[CUSTOMER][NEUTRAL] And there is
[CUSTOMER][NEUTRAL] Right, so, meaning there was, they were, they're getting treated.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] A procedure code is the.
[AGENT][NEUTRAL] A procedure code is.
[AGENT][NEUTRAL] Is the 8 like the 81002, that, that's the procedure that we perform in the visit. OK, so what are we talking about?
[CUSTOMER][NEUTRAL] Right, I, I understand the difference. What I'm saying is you're stating.
[CUSTOMER][NEUTRAL] Because you're stating that you guys only pay if there was services or some sort of procedure done, done, right?
[AGENT][NEUTRAL] If there is patient responsibility applied, think of that we're the secondary, so think of that EOB that you send us as the receipt by which we're gonna pay the claim. If we look at that claim and there is no patient responsibility applied to.
[AGENT][NEGATIVE] That that procedure code then there's nothing for us to pay. Now let me look at what how this one paid. I believe it was denied one moment it looks like it was denied.
[AGENT][NEGATIVE] Right, so when we process this claim, the $10 was denied because that's not a covered benefit. The 81002, that is a payoff benefit, but there's nothing for us to pay because there was no patient responsibility attached to it.
[AGENT][NEGATIVE] The only patient responsibility for this claim was the $10 which is not covered. Now, had there been like a PR1 which is deductible, had that said $10 we would have sent $10. That's a payable procedure code and the insurance company applied patient responsibility.
[CUSTOMER][NEUTRAL] Got you. OK, definitely, um, can I just get a reference number for this call?
[AGENT][NEUTRAL] Does that make sense?
[AGENT][NEUTRAL] Reference is just my name [PII] last initial [PII], and the date and time of the call. Was there anything else that I could assist with today?
[CUSTOMER][NEUTRAL] Core uh.
[CUSTOMER][NEUTRAL] Yes, hold on, give me a sec.
[CUSTOMER][NEUTRAL] And then the date for today?
[AGENT][NEUTRAL] Today's date is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alrighty sounds good thank you so much for your time.
[AGENT][POSITIVE] Thank you for