AccountId: 011433970860
ContactId: 21c0d27e-5adf-4335-a669-2e375b525387
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 652890 ms
Total Talk Time (AGENT): 169620 ms
Total Talk Time (CUSTOMER): 199439 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/25/21c0d27e-5adf-4335-a669-2e375b525387_20250425T20:10_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, ma'am. My name is [PII] with initial last name [PII] and I'm calling for a claim status.
[AGENT][NEUTRAL] I can verify claim status. May I have a policy number?
[CUSTOMER][NEUTRAL] Yes, ma'am. Just a moment.
[CUSTOMER][NEUTRAL] So, the policy number of the member is 01963575.
[AGENT][NEUTRAL] May I have a good callback number for you?
[CUSTOMER][NEUTRAL] Yes, ma'am. The callback number is [PII] with an extension number of [PII].
[AGENT][NEUTRAL] Thank you. May I have the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yes, ma'am. The patient's name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for verifying that information. May I have the date of service?
[CUSTOMER][NEUTRAL] Yes, ma'am. The data service is [PII].
[AGENT][NEUTRAL] Total bill amount?
[CUSTOMER][NEUTRAL] Total bill amount is $250.
[AGENT][NEUTRAL] Thank you. For future reference, you may visit our website at [PII] to check claim status as well.
[AGENT][NEUTRAL] This process under the claim number 3521531.
[AGENT][NEUTRAL] It looks like for CPT 80305, the primary paid in full. The [PII] office visits are not covered.
[CUSTOMER][NEGATIVE] Office visits are not covered.
[AGENT][NEUTRAL] So this
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] This claim processed and denied on [PII].
[CUSTOMER][NEUTRAL] [PII] and [PII]. Um, I, ma'am, I already have an EOB of uh the claim, but that's the EOB of the duplicated claim. So, um, can you tell me about the original claims?
[CUSTOMER][NEUTRAL] Is it denied for the same reason?
[AGENT][NEUTRAL] It looks like there was another claim submitted, um, claim number 3523257 is denied as a due.
[CUSTOMER][NEUTRAL] And at night for the same reason, ma'am?
[AGENT][NEUTRAL] It was denied as a duplicate, yes.
[CUSTOMER][NEUTRAL] Oh, it was denied as a duplicate again. So the reasons are that the office visits are not covered, so they are not covered services for 99215, right?
[AGENT][POSITIVE] That is great.
[CUSTOMER][NEUTRAL] And about 80305?
[AGENT][NEUTRAL] Looks like the primary insurance paid in full.
[CUSTOMER][NEUTRAL] Paid in full.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] primary chance for
[CUSTOMER][NEUTRAL] OK, ma'am. Just a moment, ma'am.
[CUSTOMER][NEUTRAL] Um, ma'am, uh, so you said that 80305, the primary insurance paid in full and the 99215 is denied because the office visits are not covered, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEGATIVE] But in my system, it shows that 99215 is paid and 80305 is denied.
[AGENT][NEUTRAL] OK, according to this policy, this policy provides no benefits for office visit benefits.
[AGENT][NEUTRAL] You have 180 days to appeal the claim.
[CUSTOMER][NEUTRAL] 180 days.
[CUSTOMER][NEUTRAL] To
[CUSTOMER][NEUTRAL] Um, so my question is still there that it still shows you the 9, the 80305 paid by the primary.
[AGENT][NEUTRAL] It shows that the 80035 paid by the primary.
[CUSTOMER][NEUTRAL] 80035.
[AGENT][NEUTRAL] 80305. Do you have an EOB that shows co-pays, co-insurance, and or deductibles?
[CUSTOMER][NEUTRAL] Yes, ma'am, but I told you that the UBI have was uh from the duplicated one, so it doesn't show anything on that one.
[AGENT][NEUTRAL] OK, so the decision will stand as far as being paid in full by the primary unless we get a different EOB that shows patients responsibility, the co-pays the co-insurance and our deductibles have been applied.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] Yes, ma'am. Uh uh my confusion is still there. So, let me talk to my supervisor just for, uh, one minute again, ma'am, if you can please wait.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] If she's pay me, I will transfer this call to her and then she will talk, just let me talk to her for just one minute, OK? Thank you for your patience, ma'am.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, OK, ma'am. So can you please tell me about the denied balance? How much is the denied balance?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] How much is the balance that was denied?
[CUSTOMER][NEGATIVE] Denied balance.
[AGENT][NEGATIVE] The office visit provider billed $200. It was denied, it's not covered. The treatment line looks like $50. It was denied. The primary paid in full.
[AGENT][NEGATIVE] So nothing was payable on this claim.
[CUSTOMER][NEGATIVE] $50.50 dollars are denied because of what?
[AGENT][NEUTRAL] Primary insurance paid in full.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Ah
[CUSTOMER][NEGATIVE] This is a crossover claim, so why is it not covered? Why are the benefits are not being covered?
[AGENT][NEGATIVE] It it's not covered. There is no co-pays. There's no coinsurance, there is no deductible for us to process.
[AGENT][NEUTRAL] This is the secondary policy.
[AGENT][NEUTRAL] We're not primary.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So because of there is no beer, uh, the office visits are.
[CUSTOMER][NEUTRAL] Not, uh, like provided services like this, uh, covered services are not the offices because there are, there is no PR, right?
[AGENT][NEGATIVE] There's no patient responsibility on the 2nd line. Office visits are not covered.
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][POSITIVE] OK, ma'am. Uh, I think that's enough for today and thank you for your time and your patience.
[AGENT][POSITIVE] [PII], you're so welcome and thank you.
[CUSTOMER][POSITIVE] Have a great day.
[AGENT][POSITIVE] Thank you for calling American Public Life [PII]. Have a great day. Bye-bye.
[CUSTOMER][NEUTRAL] Oh, hello?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh sorry, ma'am. I forgot about the reference number. So can you please provide me your reference number for this call?
[AGENT][NEUTRAL] It will be my name, which is [PII] Last initial is [PII] along with today's date.
[CUSTOMER][POSITIVE] OK ma'am, thank you for your thank you for that. OK, bye bye.
[AGENT][NEUTRAL] Bye bye.