AccountId: 011433970860
ContactId: 19ddf74c-ec90-4d76-9c35-d0629716dd4e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 687940 ms
Total Talk Time (AGENT): 149402 ms
Total Talk Time (CUSTOMER): 236381 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/24/19ddf74c-ec90-4d76-9c35-d0629716dd4e_20250224T15:22_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah, hi. This is [PII] and I'm calling for providers to check on the additional information about a claim that has been denied. Please note this call will be monitored and recorded for quality and training purposes. How are you doing today?
[AGENT][POSITIVE] I'm doing good. How about you?
[CUSTOMER][POSITIVE] I'm doing well thank you so much for asking.
[AGENT][NEUTRAL] May I please have a callback number?
[CUSTOMER][NEUTRAL] Sure, it will be [PII]. Is this the direct line with the no extension.
[AGENT][NEUTRAL] And may I have the policy number?
[CUSTOMER][NEUTRAL] Policy number will be 016.
[CUSTOMER][NEUTRAL] 93 01631918.
[AGENT][NEUTRAL] It's 01631918.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] May I have the patient's name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] And may I have the date of service and total bill?
[CUSTOMER][NEUTRAL] [PII] with the total charges of $184 even.
[CUSTOMER][NEUTRAL] May I know your name, please?
[AGENT][NEUTRAL] It is [PII]. Would you like for me to spell that for you?
[CUSTOMER][NEUTRAL] [PII]. Yeah. [PII], right?
[AGENT][NEUTRAL] It is spelled [PII] last [PII] of [PII] and today's date will be the call reference.
[CUSTOMER][POSITIVE] [PII] Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And I did pull that claim up that is for data service of 12524 total bill 184. How may I assist you on that claim?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] One moment, please. So this claim was processed on the date of purchase, uh.
[CUSTOMER][NEUTRAL] Um, what is the date.
[CUSTOMER][POSITIVE] Oh my gosh.
[AGENT][NEUTRAL] It was processed on 131 of [PII].
[CUSTOMER][NEUTRAL] I'm calling for.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] And I have the claim number is
[CUSTOMER][NEUTRAL] That is 355-79993, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] So this is for the CPT code which is denied this.
[CUSTOMER][NEUTRAL] [PII] has been denied.
[AGENT][NEUTRAL] The CPT code you you questioned was for the total bill charge of 184. That is not the CPT code that was submitted in for the total bill.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] It's $275.50 right?
[AGENT][NEUTRAL] That is the total bill charge, but you requested the 184.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] Oh, I'm sorry for that. So, I received the denial for this to uh the CPT 9,711,097,140.
[AGENT][NEUTRAL] OK. Are you needing to know the reason of the denial?
[CUSTOMER][NEUTRAL] Yeah, stating that I exceeded the maximum.
[AGENT][NEUTRAL] It's saying that the maximum has been met for that calendar year, but it still would be a denial because occupational therapy is not covered under this policy.
[CUSTOMER][NEUTRAL] Bess
[CUSTOMER][POSITIVE] So maximum benefit.
[AGENT][NEUTRAL] Yes, occupational therapy is not covered under this policy.
[CUSTOMER][NEUTRAL] has been met.
[CUSTOMER][POSITIVE] Maximum benefit has been met.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Occupational occupational.
[CUSTOMER][NEUTRAL] Therapy.
[CUSTOMER][NEUTRAL] It's not covered under the patient's policy, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So, do you know that information when the maximum benefit, uh maximum has been met?
[AGENT][NEUTRAL] It would have been made on a previous claim, so I can't advise you of that.
[CUSTOMER][NEUTRAL] Oh, it does not have any other information, right?
[AGENT][NEUTRAL] That claim is not one of your claims cause so I can't give you any information on another claim.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So may I know the patient's plan name?
[AGENT][NEUTRAL] This is their med link, their supplemental plan.
[CUSTOMER][NEUTRAL] Medlik, Medlink, right? M A D L I N K, right?
[AGENT][NEUTRAL] Midlink.
[CUSTOMER][NEUTRAL] Yeah, MED, right?
[AGENT][NEUTRAL] MED, yes.
[CUSTOMER][NEUTRAL] OK. Medicare supplement, medical supplement policy. Got it.
[CUSTOMER][NEUTRAL] So as
[CUSTOMER][NEUTRAL] So uh as uh remaining charges will be the patient responsibility of provide us right now.
[AGENT][NEUTRAL] That's the provider's discretion.
[CUSTOMER][NEUTRAL] Hold on a moment.
[CUSTOMER][NEUTRAL] So, uh, Medicare will be the patient responsibility, right?
[AGENT][NEUTRAL] That is the provider's discretion.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, shall we want the next member?
[AGENT][NEUTRAL] May I have the next policy number?
[CUSTOMER][NEUTRAL] Yes, just a moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. The next policy number will be
[CUSTOMER][NEUTRAL] Which is 016176605, M as in Mary, L as in Lima, number 8.
[AGENT][NEUTRAL] OK, could you repeat that number again please?
[CUSTOMER][NEUTRAL] 01617605 M as in Mary, L as in Lima, number 8.
[AGENT][NEUTRAL] May I have the patient's name and date of birth?
[CUSTOMER][NEUTRAL] It is [PII]. The date of birth is [PII].
[AGENT][NEUTRAL] And may I have the date of service and total bill?
[CUSTOMER][NEUTRAL] The rate of service will be 21 [PII]. Total charges of
[CUSTOMER][NEUTRAL] $501. Sorry, one moment. The total charges will be
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Total charges of $1,297.60.
[AGENT][NEUTRAL] And what was that month?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Can I provide you, let me know once you pull up the claim.
[AGENT][NEUTRAL] Yes, you can provide the claim number.
[CUSTOMER][NEUTRAL] Claim number is 3,559,370. Am I right?
[AGENT][NEUTRAL] OK, we do have another claim number in regards to that claim as well.
[CUSTOMER][NEUTRAL] OK, claim number it was processed on [PII], right?
[AGENT][NEUTRAL] I'm pulling both of those claims up.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] So for the claim number with the total bill of $1,297.16 60 cents.
[CUSTOMER][NEUTRAL] So this plan does not cover the medication or the deductible, right?
[AGENT][NEUTRAL] I did
[AGENT][NEUTRAL] You said it's what?
[CUSTOMER][NEUTRAL] So the CPT code 7311073130J 0702 was denied.
[AGENT][NEUTRAL] Yes, it was denied the previous claim that was submitted in, it shows that it denied that office visits or office procedures are not covered under the patient's plan.
[CUSTOMER][NEUTRAL] Office visits, OK, are not covered.
[AGENT][NEUTRAL] No office procedures.
[CUSTOMER][NEUTRAL] Yeah, office procedures. OK. Office procedures.
[CUSTOMER][NEUTRAL] are on record under the patient's plan.
[CUSTOMER][NEUTRAL] And the patient's plan name is?
[AGENT][NEUTRAL] This is a supplemental as well. All their plans are supplemental.
[CUSTOMER][NEUTRAL] Metallic supplemental policy. The remaining charges will be the patient's responsibility, right?
[AGENT][NEUTRAL] That is the provider's discretion. We can't tell the provider how to bill.
[CUSTOMER][NEUTRAL] I don't provided how to bill, OK.
[CUSTOMER][POSITIVE] Thank you so much for providing the valuable information and assistance. Have a good one and take care.
[AGENT][POSITIVE] You're welcome. Thank you so much for calling American Public Life, [PII]. Have a great day as well.