AccountId: 011433970860
ContactId: 0efbbff9-7319-438f-a7db-b056f82e7701
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 478660 ms
Total Talk Time (AGENT): 201837 ms
Total Talk Time (CUSTOMER): 184765 ms
Interruptions: 0
Overall Sentiment: AGENT=1.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/17/0efbbff9-7319-438f-a7db-b056f82e7701_20250217T14:51_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][NEUTRAL] Yeah, hi, [PII]. This is [PII] calling from Byram Healthcare Center.
[CUSTOMER][NEUTRAL] And I want to check the claim status. Could you please help me out with that?
[AGENT][POSITIVE] It would be my pleasure to assist you. And what was your name again, please?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. It is
[CUSTOMER][NEUTRAL] [PII]. Initial of my last name is [PII].
[AGENT][POSITIVE] Thank you, [PII]. And what is a good callback number, please?
[CUSTOMER][NEUTRAL] Uh, it is [PII].
[AGENT][POSITIVE] Thank you and the policy number for the patient, please.
[CUSTOMER][NEUTRAL] Just give me a moment. It is 01792125.
[AGENT][NEUTRAL] And the patient's name and date of birth, please, sir?
[CUSTOMER][NEUTRAL] Patient's name is [PII].
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] All right, thank you. And I understand you're needing claim status and it would be my pleasure to assist you. What was the date of service or do you have a claim number?
[CUSTOMER][NEUTRAL] Uh, I have a date of service because I don't have the explanation of benefit. D of service is 10-21-2024.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is the bill amount, please, sir?
[CUSTOMER][NEUTRAL] Building $3730.12.
[AGENT][NEUTRAL] And what is the name of the facility?
[CUSTOMER][NEUTRAL] Byron Healthcare Centers.
[AGENT][POSITIVE] All right, thank you.
[AGENT][POSITIVE] And it would be my pleasure to assist you with that claim status.
[AGENT][NEUTRAL] [PII] I'm showing that that claim was received on [PII].
[AGENT][NEUTRAL] It was processed on.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] We were able to pay $68.27 on CPTA 9277.
[AGENT][NEUTRAL] The A9276 was denied as non-covered as it did not meet the definition of covered DME according to the patient's policy.
[CUSTOMER][NEUTRAL] Uh, I'm sorry, could you please repeat again. Uh, 8892768 non covered and after that?
[AGENT][NEGATIVE] It does not meet the definition of DME according to the policy guidelines of the patient's plan.
[CUSTOMER][NEUTRAL] We plan.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. So you will not pay for this procedure called A 9276 because the no one covered DMV according to policy guideline to the patient's law.
[AGENT][POSITIVE] That is, that is correct.
[CUSTOMER][NEUTRAL] OK, could you just like, uh, give me some suggestion like what we have to do in this case to reprocess this claim.
[AGENT][NEUTRAL] Uh, you have a right to an appeal. Now, it is non-covered for the policy guidelines. The appeal does need to be submitted within 180 days for the date of denial.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And um you can fax that. We'll need a formal appeal letter stating the reason you are appealing that denial on that CPTA 9276.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, like, uh, the procedure code is now covered by DME policy guideline or the like uh the member's plan is not covered.
[AGENT][NEGATIVE] It's does not.
[AGENT][NEUTRAL] Um, follow the guidelines of the DME um definition for the policy guidelines. This CPT, the A9276, is a disposable item and this policy does not cover disposable DME items.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so we have a right to appeal and, OK, just we can file an appeal for the reprocess the claim, right? And how can we submit the appeal?
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] You can actually fax it directly to our claims department. We will need that claim number as well, the policy number claim number on the.
[AGENT][NEUTRAL] Appeal letter and I can give you the claim number.
[CUSTOMER][NEUTRAL] Yes, please provide me the claim number.
[AGENT][NEUTRAL] Claim number is 352, I'm 3550742.
[CUSTOMER][NEUTRAL] 355-0742
[AGENT][POSITIVE] Yes, sir, that's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh could you please help me with your fax number?
[AGENT][NEUTRAL] Fax number to our claims department is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So this, uh, I just want to confirm one more thing like this plan is like the procedure for a 9276, it's uh like under the pharmacy benefit or just a non-covered DME uh disposal item, or policy guidelines for patient plan.
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] It's, it's under the um.
[AGENT][NEUTRAL] DME
[AGENT][NEUTRAL] Benefit is non-covered due to it being a disposable DME item.
[CUSTOMER][NEUTRAL] OK. All right. I got it. Thank you very much for the information. So, is there like uh TFL for the appeal? Or could you please check the status of the, are we under the timely filing or uh like we have breed the timely filing, so like, did I get?
[AGENT][NEUTRAL] Yes, sir.
[AGENT][NEUTRAL] No, uh, the timely, yeah, you, you're still under the timeline to submit an appeal. It's 180 days from the date of denial.
[CUSTOMER][NEUTRAL] 120 days, right?
[AGENT][NEUTRAL] 180
[CUSTOMER][POSITIVE] 180. OK. Thank you very much for the information. Could you please, uh, just all the, uh, I just have all these things. Thank you very much for the information. And finally I have one more question. Could you please help me with your name and the call reference nu[PII]?
[AGENT][NEUTRAL] Sure. My name is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Not all reference please.
[AGENT][NEUTRAL] Oh, the call reference number, I'm sorry, is my name and today's date.
[CUSTOMER][NEUTRAL] Oh, [PII] and today's date.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][POSITIVE] OK. Thank you very much, [PII]. Thank you for the information. Thank you for the help. That's all I have today. Thank you. Have a wonderful day ahead. Bye-bye.
[AGENT][POSITIVE] I hope you have a wonderful day as well. Thank you, [PII] for calling APL and I hope you have a lovely day.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] You too. Bye-bye.
[AGENT][NEUTRAL] Bye bye.