AccountId: 011433970860
ContactId: 1eb9408c-15ed-4930-9a1b-d812be92e3dc
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 834179 ms
Total Talk Time (AGENT): 360345 ms
Total Talk Time (CUSTOMER): 353098 ms
Interruptions: 6
Overall Sentiment: AGENT=0.3, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/30/1eb9408c-15ed-4930-9a1b-d812be92e3dc_20241230T15:12_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey, um, my name is [PII]. I'm a pediatric dentist and I had, um, seen a patient that has your insured or with APL and just received the EOB after a claim and was just having a bit of a problem with, uh, the fluoride code, the 1206. Um, I had called before I had submitted and they had told me about um two older codes that are.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That are used with the insurance, uh, I think it.
[AGENT][NEUTRAL] OK. Do you have me on speaker because I can barely hear you.
[CUSTOMER][NEUTRAL] No, I don't have you on speaker. I could speak louder if you want.
[AGENT][POSITIVE] OK, that's perfect. That's better. Spell your first name for me.
[CUSTOMER][NEUTRAL] OK, sure, uh [PII]
[AGENT][NEUTRAL] And uh before we proceed, let me get the policy number, [PII], so I can pull up the account.
[CUSTOMER][NEUTRAL] 02555870
[AGENT][POSITIVE] And a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, let me pull up the patient and get them verified and then we can proceed, OK?
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Um, [PII] and uh date of birth is [PII].
[AGENT][NEUTRAL] Uh
[AGENT][POSITIVE] OK, thank you so much for that.
[AGENT][NEUTRAL] Go to his charge and is this regarding a particular date of service or has the claim not yet been filed?
[CUSTOMER][NEUTRAL] Um, it's regarding date of service 12-03-24.
[AGENT][NEUTRAL] OK, thanks for that, [PII], and you said it's um procedure code 1206?
[CUSTOMER][NEUTRAL] Um, yes, and I have a reference number for when I had spoken with someone named [PII] and, um, as well I think if you would like the reference number.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Is it her name in today's date?
[CUSTOMER][NEUTRAL] Um, 12, 0 yeah, it is.
[AGENT][NEUTRAL] OK, OK, let's see, and I'm looking at the notes.
[CUSTOMER][NEUTRAL] Oh, it's not today's date it's the date is 12-9-24.
[AGENT][NEUTRAL] OK, thank you, let me look at that.
[CUSTOMER][NEUTRAL] And the claim is actually from 1203-24. I don't know if I had uh incorrectly said 1209 the first time.
[AGENT][NEUTRAL] No, you said 12:30.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Let's see, and I do see the claim.
[AGENT][NEUTRAL] Let me look
[CUSTOMER][NEUTRAL] And I had mentioned to her.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Then on the fax back, um, I think it says that the schedule of covered dental services, it looks like it says it was last revised in [PII].
[CUSTOMER][NEGATIVE] Um, and the ADA codes that they're recommending as being covered for this patient are no from what I see are no longer active ADA codes and I can't send it on my electronic claims processor. They won't allow me to send those codes and uh um very nice lady I spoke with had said that I could, she said that they read the description of the code.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And they'll look at the description and reclassify it if appropriate more so than the code so I sent it to 1206 and it looks like it was paid at $0. It says remarks number 1 and then there's nothing on the remark side of the page as well.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm I think the remark uh description is on the back of the EOB.
[AGENT][NEUTRAL] Uh, that you may have received. OK, it should say see the policy does not provide benefits for any procedure service not listed on the schedule, OK? So you billed for D 1206 on our schedule. This is, is it fluoride treatment?
[CUSTOMER][NEUTRAL] Yeah mine mine's blank mine's blank on well.
[CUSTOMER][POSITIVE] Correct, yep, yep, yep, exactly.
[AGENT][NEUTRAL] Or child, let's see.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And I called my claims processor and they said there's no way I could send out 1203.
[AGENT][NEUTRAL] Well, generally we would catch that code, um, because on our schedule it has not been updated. I do believe 1206 is the updated code, isn't it?
[CUSTOMER][NEUTRAL] It is correct. There's two different fluoride codes. Most people use 1206 for the varnish, and then there's also like the old fluoride, like the tray foam, and I'm not sure that might be 1208 that I don't think anyone uses anymore.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Give me just a moment, OK?
[CUSTOMER][NEUTRAL] Sure
[AGENT][NEUTRAL] And so basically when you bill you cannot use bill it you cannot bill with the 12 I think we have a 12.
[AGENT][NEUTRAL] 03 for a dependent child.
[CUSTOMER][NEUTRAL] Yes, that's what the pro fee not included and then there's 1201 with the pro fee included, so I, I just submitted the pro fee separate and the fluoride separate as we usually do with the 1206, and I cannot build the 1203 through my um electronic claims processor. I can't anyway.
[AGENT][NEUTRAL] Included. OK. Got it.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Got it. I, yeah, I get that. Um, and so you said that it's, it's, uh, the propy is included or is not?
[CUSTOMER][NEUTRAL] Um, I, I've never seen those codes before, so on my first attempt I just submitted it as a separate child proofy, the 11/20, and then I submitted the 1206 for the separate fluoride varnish.
[AGENT][POSITIVE] Got it, got it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's what we do with every other insurance um for pediatrics.
[AGENT][POSITIVE] Correct. OK.
[AGENT][NEUTRAL] So on our schedule we do have it billed out just for the pro fee, the 11:20, which I see you receive payment for that code.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] OK, and so the 1206 you were basically billing without the pro fee correct?
[CUSTOMER][NEUTRAL] Yeah yeah that was the attempt.
[AGENT][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me do this. I'm gonna reach out to that team because generally because our schedule is not updated, um, I think 1206 is the most recent ADA code for that type of service.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And give me just a moment, let me reach out to that area, OK?
[CUSTOMER][NEUTRAL] OK, and I may have to step away to see a patient, but I'll be on the line, and if not I will transfer you to one of my front team members in case I do have to step away.
[AGENT][NEUTRAL] OK, sure, one moment.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] [PII], how may I assist you?
[AGENT][NEUTRAL] [PII], hi, this is [PII]. How are you?
[CUSTOMER][POSITIVE] I'm great, Ms. [PII]. How you doing?
[AGENT][NEUTRAL] Good. I have a dental question.
[AGENT][NEUTRAL] Do you want me to see if I can get somebody else?
[CUSTOMER][NEUTRAL] Mm, I can see if I can help you, but I don't process them, so what's the policy number?
[AGENT][NEUTRAL] I don't think
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Uh, no, but this is the dental cue, so you're it.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] It is 255.
[AGENT][NEUTRAL] 5870 and it's for part two.
[CUSTOMER][NEUTRAL] I'm gonna tell what [PII] did, babe. OK, is it a client?
[AGENT][NEUTRAL] And it's
[AGENT][NEUTRAL] Yeah, I think [PII] did this one yeah it is it's the only claim that he has.
[AGENT][NEUTRAL] And let me ask you this question. I think you may know it. So, you know, the profies, the, the tropical fluoride that includes the prophy and there's a code without it. Our schedule, the ADA codes are not updated. Mhm and usually when we get one that they're using the.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] It's not updated.
[AGENT][NEUTRAL] The new code
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We denied it, but it is actually the, the correct code. And I know [PII] usually kind of catches those, but we denied it, it's not covered.
[CUSTOMER][NEUTRAL] What's the 1206, um, it's.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] And so the 12:06 replaced the 1203.
[CUSTOMER][NEUTRAL] 2.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Yeah, cause it's covered. It's falls on the preventative services.
[AGENT][NEUTRAL] Right. And you.
[CUSTOMER][NEUTRAL] Unless it's varnished, is it varnished though?
[AGENT][NEUTRAL] It's not, he, so he had that they built for the um the trophy, the cleaning with the fluoride application.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And so what they did was they build the 1120, they build the the the cleaning under the 1120.
[AGENT][NEUTRAL] And then they built for the fluoride application without the trophy or the cleaning.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 2 hours.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Which is the the 1203.
[AGENT][NEUTRAL] On our schedule but he billed it as the 1206, which is the most current procedure code.
[CUSTOMER][NEGATIVE] Schedule. I wanna know why they don't update those.
[AGENT][NEUTRAL] I know it.
[CUSTOMER][NEUTRAL] And it's just a little bit less frustrating.
[AGENT][NEUTRAL] Uh, no. It would be.
[AGENT][NEUTRAL] And so usually when [PII] pro, you know, she usually kind of.
[CUSTOMER][NEUTRAL] It the system normally would change like I know when I processed them to the codes weren't updated, but the system will still pay it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And so
[CUSTOMER][NEUTRAL] So she needs to reprocess claim.
[AGENT][NEUTRAL] Do you show that it was [PII]? Is that [PII] or [PII]'s initials?
[CUSTOMER][NEUTRAL] I ain't know [PII] process claims, but let me, I mean dental claims, but let me make sure.
[AGENT][NEUTRAL] Um, maybe I'm wrong. [PII] Let me see who that is. OK, I thought that was her initials.
[CUSTOMER][NEUTRAL] That's [PII].
[CUSTOMER][NEUTRAL] I don't know on the process on the [PII].
[AGENT][NEUTRAL] And when was it processed? She was probably.
[AGENT][NEUTRAL] OK, just recently she probably was back up or something like that.
[CUSTOMER][NEUTRAL] It's processed on the [PII]. It just processed a couple of week last week or week is gonna last.
[AGENT][NEUTRAL] Just recently, mhm.
[AGENT][NEGATIVE] She must have been back
[CUSTOMER][NEUTRAL] Oh that's probably why, but it normally would pay it though when I processed it, it would pay it cause it was.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Just caught it I don't know.
[AGENT][NEUTRAL] Yeah, and I, I looked at her own team she's out, so that's why I called the queue. I was gonna reach out to her.
[CUSTOMER][NEUTRAL] So somebody needs to reprocess it.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, I'll send it through. Is [PII] here?
[AGENT][NEUTRAL] Uh, she's away.
[AGENT][NEUTRAL] I'll, I'll reach out to you.
[CUSTOMER][NEUTRAL] And uh, so are you gonna send an error document or?
[AGENT][NEUTRAL] Well, I don't know. I'll send it through. I'll I'll do a hub request.
[CUSTOMER][NEUTRAL] Do you know how to spin it?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] A help request.
[CUSTOMER][NEUTRAL] Oh, OK. I think they, they changed it some kind of way. You know how when we used to get an error they send the error document.
[CUSTOMER][POSITIVE] Don't worry, I got a new way to do it now.
[AGENT][NEUTRAL] But I don't think
[AGENT][NEUTRAL] Our roles have kind of changed so we can't go in and do that part anymore because it's a claim function we just have to send a hub request, but I'm gonna reach out to [PII] before I do that.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Cause she just kind of go back in and reprocess it.
[CUSTOMER][NEUTRAL] If she only look like just the one line she needs to reprocess, but.
[AGENT][NEUTRAL] Right. Right.
[CUSTOMER][NEUTRAL] I don't know why the system didn't change it. It normally would change it.
[AGENT][NEUTRAL] Yeah, um, but I'm, I wish we could get our schedule updated because it's that code, it's two codes that we need to update.
[CUSTOMER][NEUTRAL] Yeah, well I'm.
[AGENT][NEUTRAL] Well, it's just the fluoride, but it's the child and the adult. Both of those need to be updated.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yeah, I agree.
[AGENT][NEUTRAL] No.
[AGENT][POSITIVE] All right, Ms. [PII], thank you.
[CUSTOMER][POSITIVE] You're welcome, Ms. [PII]. It was nice hearing from you. Have a good one and [PII]'s if I don't talk to you again.
[AGENT][NEUTRAL] You too.
[AGENT][NEUTRAL] OK, same to you.
[CUSTOMER][POSITIVE] Thank you. Bye.
[AGENT][NEUTRAL] Uh-huh. Bye-bye.
[AGENT][NEUTRAL] Hi, [PII].
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] OK, so what, what I'm gonna do, I'm gonna have the examiner take a look at this one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And see if we can go back in and reprocess it. I'll call you back with the outcome.
[AGENT][NEUTRAL] Now is this your number your direct line? [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, it is
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's the office it's the office line.
[AGENT][NEUTRAL] Do I just ask for you?
[CUSTOMER][NEUTRAL] Um, sure, yeah, you could do that where the person usually answers is [PII], and she's also, um, in the loop on the claim.
[AGENT][POSITIVE] OK. OK. Very good. All righty, so I will call you back with the outcome, OK?
[CUSTOMER][POSITIVE] OK sounds great thank you for your patience and all your help I really appreciate it.
[AGENT][NEUTRAL] Oh, you're welcome, [PII]. Did you have any other questions?
[CUSTOMER][POSITIVE] Nope, that's all thank you I really appreciate it hope you have a great day.
[AGENT][POSITIVE] Absolutely. Thanks for calling APL. Have a good day as well.
[CUSTOMER][POSITIVE] OK you too bye bye.
[AGENT][NEUTRAL] Bye-bye.