AccountId: 011433970860
ContactId: 10772535-5bf0-47a4-bf08-4056a098dd3b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 865000 ms
Total Talk Time (AGENT): 343654 ms
Total Talk Time (CUSTOMER): 360329 ms
Interruptions: 6
Overall Sentiment: AGENT=1.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/18/10772535-5bf0-47a4-bf08-4056a098dd3b_20250318T19:10_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good afternoon thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from Sanchem Clinic to check on a claim status.
[AGENT][POSITIVE] [PII], it would be my pleasure to assist you with that claim status. What is the callback number?
[CUSTOMER][NEUTRAL] [PII] with the extension [PII].
[CUSTOMER][NEUTRAL] Which.
[AGENT][NEUTRAL] Thank you, [PII]. And what is the policy number for the patient, please, ma'am?
[CUSTOMER][NEUTRAL] It is 225-0022.
[AGENT][NEUTRAL] Thank you, [PII] and the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] The patient's name is [PII] and the date of birth is [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][POSITIVE] And it would be a pleasure to assist you with that claim status for [PII]. What is the date of service?
[CUSTOMER][NEUTRAL] [PII] for $1330 even.
[CUSTOMER][NEUTRAL] Like.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] OK, bear with me just one second.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And what is the facility name?
[CUSTOMER][NEUTRAL] Samsung Clinic.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] [PII], we did receive that claim on [PII], 2024.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] The claim was processed on 8-16-24.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] 99213.
[AGENT][NEUTRAL] And 90734.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] Is the claim number?
[AGENT][NEUTRAL] The claim number is 34933943493393 and it was denied as this policy provides no benefits for the treatment or conditions other than a sickness or an injury, and that is per the policy's guidelines of the patient's plan.
[CUSTOMER][NEUTRAL] that
[CUSTOMER][NEGATIVE] OK, what is the denied reason, denied that patient policy does not cover.
[AGENT][NEUTRAL] the policy provides.
[AGENT][NEUTRAL] For any conditions other than sickness or injury.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Fitness and injury.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Uh, under the patient policy, you only cover fitness and injury. Rather than that, you will not cover any other services.
[AGENT][NEUTRAL] That
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But the be courts are not related to fitness or injury. One is related to blood count.
[AGENT][NEUTRAL] The CPT.
[AGENT][NEUTRAL] 8500 I'm sorry 85018.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] 81003 were denied as non-covered in a doctor's office. Those were the CPTs that did not have that wellness code.
[CUSTOMER][NEUTRAL] OK. So this is uh this is under the patient plan only, right? Where the patient plan only covers the wellness.
[AGENT][NEGATIVE] Right. Well this, well this is not covered under this policy.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK. Well this is not covered under this policy only cover fitness and injury.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][POSITIVE] Thank you so much. And before that you have provided me some numbers, right? What is the number? I couldn't catch it.
[AGENT][NEUTRAL] I'm sorry, what is the
[AGENT][NEUTRAL] What did you need?
[CUSTOMER][NEUTRAL] You provided me the
[CUSTOMER][NEUTRAL] Receive the process date, and you provided me the claim number, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right. You need that claim number again?
[CUSTOMER][NEUTRAL] No, no, just a moment.
[CUSTOMER][NEUTRAL] So, can we build the services to patients?
[AGENT][NEUTRAL] That is determined by the provider. We're not major medical, so the provider will have to determine if you pay, bill the patient.
[CUSTOMER][NEUTRAL] OK. I request you to send a copy of COP via fax. Is that possible?
[AGENT][NEUTRAL] We do have a provider portal at [PII].
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] And it is a self registration using the tax ID number and the patient's account number listed in box 26 on the HPA. That's the quickest and the easiest way to get that EOB.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][MIXED] OK, but you cannot fax it.
[AGENT][POSITIVE] I can, but I can help you with that portal account if you want to do it that way. I can assist you and you don't have to wait for that fax to come through.
[AGENT][NEUTRAL] But I can fax it if you need to.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I have entered like secure. [PII]. It is asking like new user login. I need to click on new user.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] And then the next question.
[CUSTOMER][NEUTRAL] And yeah, I do have the option.
[AGENT][NEUTRAL] You're gonna answer the bottom, you're gonna choose the bottom question. I'm a dental provider, medical or dental provider? Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. Next, I need to give the tax ID.
[AGENT][NEUTRAL] That's right, and when you get to the patient account number I can give you that.
[CUSTOMER][NEUTRAL] Yeah, you can provide me the account number.
[AGENT][NEUTRAL] It's P as in [PII], 140874.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] 371.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then you create a um username and password. Once that's created, you'll have 24/7 access to claim status, EOBs, and you can even submit claims online as well.
[CUSTOMER][POSITIVE] OK. We will create this one as well. Thank you for the information. But meanwhile, if you, if you have any glitches on this one, you can fax us either, that would be helpful.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, but that's easy it's an easy website.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yeah, yeah. Yeah, got it, yes.
[AGENT][POSITIVE] And that'll help you a lot. Let me, let me get this ready for you. Bear with me just one second because it takes a minute to prepare the facts.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] You may get an account created by the time I get this ready for you.
[CUSTOMER][NEUTRAL] Yeah, sure, sure. I'm doing that only.
[AGENT][POSITIVE] I'm trying to get this prepared for you.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] OK, that's.
[AGENT][NEUTRAL] [PII], I'm ready for that fax number.
[CUSTOMER][NEUTRAL] Yeah, it is [PII].
[AGENT][NEUTRAL] And just to verify that fax number I'm sending this to [PII], is that correct?
[CUSTOMER][NEUTRAL] Yeah, it is [PII]. Correct.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Alright, that EOB has been faxed to you. You should be receiving it shortly.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. I do have one more claim for different patient. Can you please help me with that one?
[AGENT][NEUTRAL] I certainly can. Give me just one second.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] I'm ready whenever you are with that next policy.
[CUSTOMER][NEUTRAL] Yeah. Meanwhile, I couldn't get your name. Can you please spell it for me?
[AGENT][NEUTRAL] Absolutely. My name is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much. And the next member ID is 2250022.
[CUSTOMER][NEUTRAL] I was
[AGENT][NEUTRAL] 225. Can you repeat that?
[CUSTOMER][NEUTRAL] 2250022
[AGENT][NEUTRAL] That's the same policy number, is it for the same?
[CUSTOMER][NEUTRAL] Different patient I have. Here I have like [PII].
[AGENT][NEUTRAL] Hey
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And what is Holiday's date of birth?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alright thank you and what is that data service?
[CUSTOMER][NEUTRAL] The date of service is [PII] for the bill amount of $1,397 even. And I do have a specific question on this 10.
[AGENT][NEUTRAL] OK, I've got that claim pulled up. How can I help you?
[CUSTOMER][NEUTRAL] Yeah, actually, it was denied as uh inconsistent place of service. We have reserved the denial. But after primary process to claim the secondary insurance cannot be denied as this coding related. Can you please check uh uh on the denial once again?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So for the procedure, 850-1892551 and 81003, those were denied as services are not covered when performed in a doctor's office. The other codes were denied as the policy only pays towards sickness or injury. Wellness is not covered.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEGATIVE] Same denial as the other claim.
[CUSTOMER][NEUTRAL] Yeah, I do have only 2.
[CUSTOMER][NEUTRAL] Yeah, I do have only two CPT codes which are outstanding, same as the previous claim, which are 81003 and 85018 which is related to blood count and other one is also. So what is the demand clarification on this one?
[AGENT][NEUTRAL] Services are not covered when performed in a doctor's office, so it's the place of service.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] But how can it can be denied after the primary has processed the claim with the same place of service, the secondary insurance cannot be denied, right?
[AGENT][NEUTRAL] That is, that, well, it can because it's not covered.
[AGENT][NEUTRAL] Per the policy, the guidelines of the patient's plans not covered on her secondary gap policy.
[CUSTOMER][NEUTRAL] Hey.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's just not a covered service on this policy.
[CUSTOMER][NEUTRAL] Is it related to
[CUSTOMER][NEUTRAL] So, if, if it is, it is not related to place of service, right? It is related to the patient policy.
[AGENT][NEUTRAL] Right, but if
[CUSTOMER][NEUTRAL] Yeah that's
[AGENT][NEUTRAL] For example, if it is performed in a doctor's office under this policy, no services are covered in a doctor's office.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Services.
[AGENT][NEGATIVE] So because it was in a doctor's office, it's not covered.
[CUSTOMER][NEUTRAL] So, uh, I just stated, what are the services will cover under this patient plan rather than offer.
[AGENT][NEUTRAL] Mhm. It would be for inpatient hospitalization and outpatient hospital facilities.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] You'll cover inpatient and outpatient but not the doctor's office, right?
[AGENT][POSITIVE] That's right. Now an independent laboratory facility is covered.
[AGENT][NEGATIVE] But because that lab work was in a doctor's office, it's not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much for that information. So, can I get the call reference number?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The call reference number is my name in today's date. Do you need me to spell my name again?
[CUSTOMER][NEUTRAL] Uh, no, no. Just to confirm on the previous claim, the denially stated, uh, the, uh, the claim was denied, uh, it is not covered under the patient plan where it only covers the fitness and injury. The bill cos which are related to wellness, so it will not cover, right?
[AGENT][POSITIVE] That's right.
[CUSTOMER][POSITIVE] OK, got it. Uh, thank you so much, [PII], and assisting on the claims and that's all for the day. Have a great day.
[AGENT][POSITIVE] It's been my pleasure to assist you. Is there anything else I can help you with today, [PII]?
[CUSTOMER][POSITIVE] Yeah, nothing else. Thank you so much for assisting the information. Have a great day.
[AGENT][POSITIVE] And thank you for calling APL. I hope you have a wonderful day as well. Take care.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] OK, thank you.