AccountId: 011433970860
ContactId: 15f30f62-b2fb-4fbf-87cc-9f716fcd5155
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 775429 ms
Total Talk Time (AGENT): 454188 ms
Total Talk Time (CUSTOMER): 168409 ms
Interruptions: 2
Overall Sentiment: AGENT=0.3, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/24/15f30f62-b2fb-4fbf-87cc-9f716fcd5155_20250424T21:19_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. I was returning your call.
[AGENT][NEUTRAL] Hi [PII] how are you?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][POSITIVE] Good thanks um just give me one moment to pull that patient's information back up.
[CUSTOMER][NEUTRAL] Yes ma'am, sorry about that. I had bad service where I was at.
[AGENT][NEUTRAL] Oh, that's fine.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Sorry, I was right in the middle of another screen so just.
[AGENT][NEUTRAL] Bear with me please.
[CUSTOMER][POSITIVE] Yeah, take your time.
[AGENT][NEUTRAL] And this uh claim was for [PII], right?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] And there was a question as to why the office service wasn't paid. doesn't look like it was an office visit. Let me pull that information back up here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it looks like um we received the bill for 2 services um and it was a chiropractic office so we paid that X-ray benefit.
[AGENT][NEGATIVE] And then the additional benefit was denied is not covered, uh, not covered within the plan, uh, not covered within the plan.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, the benefit is not available. So, um, they're limited to what's, uh, you know, outlined in the, uh, policy. So this service looks like it was an ultrasound. Again, um, it's a chiropractic service, so that is not covered under the physician. The definition of a physician, the chiropractor doesn't meet the definition of a physician.
[AGENT][NEUTRAL] So that particular service though was denied is not covered based on that uh out was outlining the benefits.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] Um, sorry, I'm making notes.
[AGENT][NEUTRAL] That's OK. And, and you know the um patient does have a right to appeal, you know, the insured um if they disagree with that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Determination.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] So I had to we had another employee who had filed a claim.
[CUSTOMER][NEUTRAL] And the, I don't know if it was the physicians.
[CUSTOMER][NEUTRAL] Office benefit that was paid out or if it was the physical therapy benefit there but there was.
[CUSTOMER][POSITIVE] Benefits paid out for the visit, um.
[CUSTOMER][NEUTRAL] And I remember speaking, I forgot who I had spoken to, but they had.
[CUSTOMER][NEUTRAL] Asked for I guess the physician's code because
[CUSTOMER][NEUTRAL] A chiropractor is kind of in there. They are they are a doctor, but then it's also
[CUSTOMER][NEUTRAL] You know, I'm gonna, I, I forgot the technical term for it, but basically I took it as like physical therapy like wellness, um, but they are in their, they're also in their own category.
[AGENT][NEUTRAL] Right, and the physical, well, and the
[CUSTOMER][NEUTRAL] Is that the case here where we would just need his.
[CUSTOMER][NEUTRAL] Number or something?
[AGENT][NEUTRAL] Yeah, so what happens here is we go to basically you rely on that definition of what is um in the policy. So the definition um for physical therapy it has to be uh let me pull that up here and we're speaking of this particular policy for uh Ms. [PII] just because um I don't know, I can't speak on, you know, the other um.
[AGENT][NEUTRAL] You know, claim because I don't know what that was. So for um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] For this particular uh policy though, the physical therapy, it does need to be, um,
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Just bear with me while I pull up this policy.
[AGENT][NEUTRAL] Information.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. So what this says under the physical therapy, which is kind of where this code I believe would fall because it's uh that ultrasound treatment.
[AGENT][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It just says here and for physical therapy, um, the covered person receives physical therapy from a physical therapist, such as an individual office or clinic as a result of a covered accident, such physical therapy must follow initial treatment in a hospital, emergency room, or other medical facility for the covered accident.
[AGENT][NEUTRAL] So on this particular claim, we didn't receive, we just received that X-ray and then the treatment under the chiropractic. So it, it has to follow. So in other words, if did, for this particular accident, did they seek treatment in a hospital emergency room or a physician's office um for, for this uh service to be covered?
[AGENT][NEUTRAL] And then it says treatment and emergency room, chiropractic.
[CUSTOMER][NEUTRAL] OK, so a chiropractor isn't covered at all?
[AGENT][NEUTRAL] Well, it says treatment in emergency room, chiropractic office, physical therapist, physician's office, and or urgent care occurs on the same day, only the highest applicable benefit is payable. So in other words, if they were at a physician's office and then went to the chiropractor or the emergency room and then went to a chiropractor,
[AGENT][NEUTRAL] Only that highest benefit would be paid. But in order for the physical therapy, it has to follow that initial treatment in the hospital emergency room, or other medical facility, meaning the physician's office, um, or any other.
[AGENT][NEUTRAL] Covered entity, you know, that's under. So basically what it's saying is it must follow that initial treatment as far as the physical therapy. In other words, for the physical therapy to be covered, it has to follow that initial treatment for that accident.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and her initial treatment at the chiropractor isn't covered?
[CUSTOMER][NEUTRAL] Under the physician's benefit, correct? Because
[AGENT][NEUTRAL] Right, right, and that's what it says because it, like I said, the, the actual um denial just reads that it doesn't, it's not covered within the um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's, it's, it's limited to what is benefits are under the certificate is limited to those outlined on the schedule of benefits and it's not a covered loss under the plan so that's why the benefit wasn't paid on that particular service.
[CUSTOMER][NEUTRAL] OK, um, can you also look into the hospital claim for me? I have the claim number it's for the same person.
[AGENT][NEUTRAL] Just give me one moment.
[AGENT][NEUTRAL] And it's under the hospital indemnity?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] And is the claim number ending in 2842?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] And it's for the same service, right?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So now this particular claim was denied for um.
[AGENT][NEGATIVE] X-rays aren't the X-rays aren't covered under this plan and.
[AGENT][NEUTRAL] Let me just see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] So they both services were denied as not covered um.
[AGENT][NEUTRAL] is a diagnostic test. Now, that is correct for the X-ray, but um that other service is not uh
[AGENT][NEUTRAL] Diagnostic.
[AGENT][NEUTRAL] Now it comes up, just bear with me I'm gonna look this code up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Now, this one, because it is an ultrasound, it was denied under that diagnostic testing. It's not a covered test under the diagnostic testing because it is um an ultrasound. It falls under that diagnostic testing, um, and it was denied as not one of the covered diagnostic tests for um this particular policy.
[CUSTOMER][NEUTRAL] OK, and the, the visit to the chiropractor doesn't fall under any benefit like so.
[AGENT][NEUTRAL] Right, because it is.
[CUSTOMER][NEUTRAL] The a chiropractor is not considered a physician at all under any of these policies.
[AGENT][NEUTRAL] Well, now certain policies that may have a different definition that's why I was speaking up with that other policy that you were asking about the code because without being able to see the actual policy, um, I wouldn't wanna speak because each policy is different, um, I mean, even though, um, some of them may have the those same type of benefits, there could be different wording within the language of the policy and what the definition is, um, under each policy it could be different.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's for the same company so it would be it would be the same because it's for the same company.
[CUSTOMER][NEUTRAL] I'm, I'm just trying to.
[CUSTOMER][NEUTRAL] Figure out if
[CUSTOMER][NEUTRAL] Why a chiropractor who is a doctor isn't covered.
[AGENT][NEUTRAL] Well, now under the definition of physician, like I said, there is different definitions when it comes to a physician, but the definition itself, let's, let me look that up under this policy, and I can read you exactly what it says as far as um that definition cause a doctor of chiroprac is a, a chiropractor is a doctor of chiropractic. So he, he's not a medical physician, he's not what they consider a physician.
[AGENT][NEUTRAL] Um, when they're, um,
[AGENT][NEUTRAL] Giving that physician definition. Let me find it here in the policy and I can read it right to you.
[AGENT][NEUTRAL] So sometimes, like I said,
[CUSTOMER][NEUTRAL] OK, well that's why I was wondering if we should get the if we should get his.
[CUSTOMER][NEUTRAL] Um, I forgot the, the term I'm drawing a blank, but it was, I don't know if it was his, um.
[CUSTOMER][NEUTRAL] His physician, not like his doctor number, because some chiropractors,
[CUSTOMER][NEUTRAL] MDs as well as a kind of like.
[AGENT][NEUTRAL] Right, I see what you're saying. Sometimes they have a different designation. If they could have furthered their education, they could have a DO designation, MD or something of that nature, um, but under this particular one, he is just, uh, the, the information that's listed on this claim, it just says he's a doctor of chiropractic.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, is that, is that like a code or something that was on the form or just based off of the provider information that was what was submitted?
[AGENT][NEUTRAL] Just the provider information that was submitted his designation, then the provider information has his name with the initials DC next to it and we also did receive the um notes that um indicate that you know again his provider credentials are DC for doctor of chiropractic.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right well thank you so much for clarifying that um it helps that way I can explain it to the employee a little bit better.
[AGENT][NEUTRAL] Sure, did you have any other questions?
[CUSTOMER][NEUTRAL] Uh, that was it.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All right well thank you so much for your patience I appreciate that and thank you for giving me a call back.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Have a nice evening.
[CUSTOMER][POSITIVE] Thank you for your patience with me. You have a great day bye.
[AGENT][POSITIVE] Yeah you too bye bye.