AccountId: 011433970860
ContactId: 2ecc9f2f-e94c-41bc-b13c-d7c6fd62c857
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 2880689 ms
Total Talk Time (AGENT): 2004264 ms
Total Talk Time (CUSTOMER): 393296 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/11/2ecc9f2f-e94c-41bc-b13c-d7c6fd62c857_20250411T21:02_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APO. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] on the care team. How are you doing?
[AGENT][POSITIVE] I'm good. How are you, [PII]?
[CUSTOMER][NEUTRAL] I'm doing good. I have a uh insured on the other line. I tried to help her, but she wants to speak to somebody in claims to see if the documents that she just submitted was suffice and she has other questions. I offered to look, but she don't want me.
[AGENT][NEGATIVE] OK, then. All right. They're just getting some nitpicky people today. All right. OK.
[CUSTOMER][NEUTRAL] I said, OK, well, I'm gonna get you over to claims then.
[AGENT][NEUTRAL] What is the um policy number?
[CUSTOMER][NEUTRAL] It is 254.
[CUSTOMER][NEUTRAL] 5851.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Is it part 1 or 2?
[CUSTOMER][NEUTRAL] It's part 2.
[AGENT][NEUTRAL] Part two. OK.
[AGENT][NEUTRAL] Let me get over to what's been submitted.
[AGENT][NEUTRAL] So.
[AGENT][NEUTRAL] I'm assuming maybe we've denied uh requesting hospital bill need to itemize hospital bill with admission and discharge date and time. OK, so we've requested that so I'm assuming she's trying to figure out where he.
[AGENT][NEUTRAL] Is it the primary or the secondary that's called? OK, OK.
[CUSTOMER][NEUTRAL] Is she, it's a wife. Mhm.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Well, they're together, but she's on the phone.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Ah.
[AGENT][NEUTRAL] OK, so I have it pulled up. She just wants you said she had other questions but she's mainly wanting to verify that this is gonna be sufficient, right?
[CUSTOMER][NEUTRAL] A document mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I have it pulled up.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] All right, hold on one moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I did not write your name in my notes. What's your name? I'm sorry.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII], sorry, [PII]. OK, hold on.
[AGENT][NEUTRAL] That's OK. OK.
[CUSTOMER][NEUTRAL] Hello Mrs. [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you so much for holding I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] Thank you. You're welcome.
[AGENT][NEUTRAL] Hey, Ms. [PII], how are you?
[CUSTOMER][NEUTRAL] Hi, [PII]. How are you?
[AGENT][POSITIVE] I'm doing well, thank you.
[CUSTOMER][NEUTRAL] I am calling.
[CUSTOMER][NEUTRAL] OK, I'm calling about my claim because I wanna just, is this is for my husband, but I wanna make sure that.
[CUSTOMER][NEUTRAL] Everything that I'm supposed to get is, I'm gonna get. Um, so yesterday I sent in, um, a discharge, like the admittance and a discharge, and I wanna find out if what I sent was, was sufficient.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, let's see, I see, I'm gonna see what we received previously as well just so I can compare because it looks like we have records submitted, is that correct?
[AGENT][NEUTRAL] This time, OK, OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let's see here.
[AGENT][NEGATIVE] Sorry, my system is incredibly slow today. It's done with the week apparently.
[AGENT][NEUTRAL] Oh, OK. So he was in the hospital.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] 4:10. 0, that's a sleep study.
[CUSTOMER][NEUTRAL] Mm mm. No, that's not the uh 4, 42.
[AGENT][NEUTRAL] OK, 41342 and he was in the hospital during that time, OK.
[AGENT][NEUTRAL] OK, and then the records indicate 41.
[AGENT][NEUTRAL] He was admitted at around [PII]
[CUSTOMER][NEUTRAL] Well, that's what time they started the surgery. We had to be there for [PII].
[AGENT][NEUTRAL] Oh, got you, got you, got you. OK, all right.
[AGENT][NEUTRAL] I'm gonna make a note started surgery.
[AGENT][NEUTRAL] Fair you said around [PII]?
[CUSTOMER][NEUTRAL] Mhm, around [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, alright.
[AGENT][NEUTRAL] That may be later in the documents. That's just the first page I saw, so, OK, I do see surgery. I see that he was diagnosed with chronic kidney disease stage 2 and
[AGENT][NEUTRAL] Um, heart failure, he has a history of
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] A repair and all that.
[CUSTOMER][NEUTRAL] Yeah, but that didn't have nothing to do with his, um, yeah, so he had, he went in for knee surgery.
[AGENT][NEUTRAL] He went in for his knee. OK, OK.
[CUSTOMER][NEGATIVE] Cause he fell.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let me see if that's on here. I'm sure it is like I said, it may just be later. I just haven't gotten to it, OK.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, his tibia was loose, bless his heart.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Discharge 4142.
[AGENT][NEUTRAL] OK, follow up.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Sorry, I'm just trying to sift through these while I have you that way I can answer any questions you might have.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] They included all this information about his.
[AGENT][NEUTRAL] Heart failure issues.
[AGENT][NEUTRAL] I guess because that's in its history.
[CUSTOMER][NEUTRAL] I know.
[AGENT][NEUTRAL] I mean I know that wasn't the active issue but.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I guess they have to.
[CUSTOMER][NEGATIVE] I know, but I sent in, um, y'all should have like the attorney's, um, physician, not the attorney, the physician's statement that I sent them, but I don't even see that up there anymore.
[AGENT][NEUTRAL] OK, I do show the discharge summary. It shows [PII].
[AGENT][NEUTRAL] And that was, it shows the time [PII].
[AGENT][NEUTRAL] So, um.
[CUSTOMER][NEUTRAL] I didn't get them till like [PII].
[AGENT][NEUTRAL] OK, and then it shows reason for admission was failed left tibial component. He was there for his knee.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Principal problem mechanical complication of internal orthopedic device implant and graft.
[AGENT][NEUTRAL] OK, so I have an actual diagnosis code. I see that.
[AGENT][NEUTRAL] Um, and he was being discharged to home health care services. Is that correct?
[CUSTOMER][NEUTRAL] Mhm. Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So did you, I'm assuming you had someone coming out to you um in your home for like physical therapy and stuff?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Well, there
[CUSTOMER][NEUTRAL] Mhm. Well they come in for physical therapy, um, and I think he has to start next week. It's outpatient therapy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I feel like I've spoken with you previously. He was there for the same issue, right? Like he went in.
[AGENT][NEUTRAL] For this and then had to go back. Is that correct?
[CUSTOMER][NEUTRAL] Well, he went in to, to find out about his knee. And then, um then they decided he needed to have surgery.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][POSITIVE] Goodness.
[AGENT][NEUTRAL] OK, and you said the physician's statement is in here as well somewhere.
[CUSTOMER][NEUTRAL] Well, the uh, the doctor sent the original statement and they faxed it in to you guys and I faxed it into you guys previously last week.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Last week, OK, let me look at what we received because I do have something from last week, so let me look at.
[AGENT][NEGATIVE] What we received because it may be in the midst of all that I want to.
[AGENT][NEUTRAL] Verify because that'll help as well um I mean I we have sufficient information I feel like to move forward with processing and considering this claim um let me see what this page is statement of insured fell out of the bed had to have surgery.
[AGENT][NEUTRAL] Had surgery on [PII], OK.
[AGENT][NEUTRAL] Um, and then that's the billing related to all that.
[AGENT][POSITIVE] That looks like billing as well.
[AGENT][NEUTRAL] And then OK let me see what this is oh, I think I see it OK.
[AGENT][NEUTRAL] Yeah, I think I see it very last page.
[AGENT][NEUTRAL] OK, so this is.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] He was diagnosed on [PII].
[AGENT][NEUTRAL] Fall out of bed in January.
[AGENT][NEUTRAL] And then they have this.
[AGENT][NEUTRAL] Diagnosis code, the TA4498.
[AGENT][NEUTRAL] Mechanical complications which is listed in the medical records you did as well, OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah I think I think that's it I mean it looks like the last thing we had like the last um thing submitted which you may just not have it yet because it was processed yesterday um we had denied what you submitted because it was the billing asking for.
[AGENT][NEUTRAL] The admin and discharge dates and times. I don't know if you called to request what it was, so now that we have that you can disregard that denial because what we're gonna do is we're gonna use that information with what you've previously submitted and we'll consider benefits based off of all of that information combined.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Now, are you an adjuster?
[AGENT][NEUTRAL] Um, I'm an auditor, so kind of.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I have, I have done it just um claims processing previously, yes, ma'am.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Well, well, I mean claims processing. So what I'm thinking is just looking at the schedule of benefits, um, what if he was to receive what would he receive it for?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So if the examiner looking at it.
[AGENT][NEUTRAL] Which again we typically do review these after the examiner so there is a possibility that we catch something that they may not have so just based off of what I know about the situation and what they may be looking for, they're gonna be looking at hospital admission confinement. Now I will let you know admission and confinement are not payable on the same day since he was only there for one day.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You likely will only get the admission benefit.
[AGENT][NEUTRAL] That is the higher paying benefit so you likely will not get both because it's not payable on the same day and he wasn't there for more than one day.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, um, based off of that information, probably just the hospital admission, um, when you're looking at both of those, as far as the.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Surgery, he didn't have a fracture necessarily based off of this remark code, like they weren't fixing a fracture. He
[AGENT][NEUTRAL] They didn't code it as a fracture. Let me just say that. Um, let me see what surgery codes they used.
[AGENT][NEUTRAL] Cause if they
[AGENT][NEUTRAL] Coded it
[AGENT][NEUTRAL] like diagnosis code wise with something different, um, or if they have like a surgery code here that says this, um, it looks like.
[AGENT][NEUTRAL] Did he have a hip replacement?
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Or was it just his knee?
[CUSTOMER][NEUTRAL] What was his name? Why they called it it as the help.
[AGENT][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] I don't think I just saw something that said hip and I was like hang on a second, that's weird um because everything else says knee and that's why I was like wait, what is going on here? I'm confused. OK, um, it's probably just an abbreviation for something. OK.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] So.
[AGENT][NEUTRAL] I don't see the actual surgery.
[AGENT][NEUTRAL] Code. I do see that he had surgery. I don't see the surgery code. That's not an issue. I was just trying to see like, did they.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Did the surgery indicate?
[AGENT][NEUTRAL] You know, a fracture or is it just a knee replacement? Um.
[AGENT][NEUTRAL] Because he's having issues so or because he fell and.
[AGENT][NEGATIVE] Basically wasn't getting better. So your policy pays for like fractures and dislocations um and burns. I'm trying to see.
[AGENT][NEUTRAL] Let's see, there are other inpatient surgeries for repair, may fall up under that. Um, let me see what that benefit considers.
[AGENT][NEUTRAL] Because that may be what it is since it's not a fracture or dislocation it may be considered up under that one let's see.
[AGENT][NEUTRAL] Inpatient surgery.
[AGENT][NEUTRAL] OK, undergoes an invasive or open surgery for repair while confined.
[AGENT][NEUTRAL] And as an inpatient in a hospital as a result of a covered accident.
[AGENT][NEUTRAL] The amount we pay will be based on the top of surgery. Surgery must be performed by a physician within 90 days. OK, um, after the accident.
[AGENT][NEUTRAL] Mm, that.
[CUSTOMER][NEUTRAL] It must be performed when?
[AGENT][NEUTRAL] Within 90 days after the accident.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But it was late January, right, when he had this?
[CUSTOMER][NEUTRAL] Yeah, it's been before 90 days.
[AGENT][NEUTRAL] OK. So I feel,
[AGENT][POSITIVE] Yeah, I was, I was fixing to say, I think, I think you're well within the 90 days, um.
[AGENT][NEUTRAL] So I think
[AGENT][NEUTRAL] We're gonna be looking at that benefit, um.
[CUSTOMER][NEUTRAL] Which one?
[AGENT][NEUTRAL] As the inpatient surgery. So essentially, because it's not a fracture or a dislocation under the inpatient surgery, um, there's
[AGENT][NEUTRAL] Let's see, it says other inpatient surgeries for repair. It doesn't, it doesn't indicate what type of repair or what type of surgery. It's just it has to be due to a covered accident and you have to be receiving a repair. Um, that is what I'm thinking since he was inpatient is where you're going to fall as far as that benefit. So the other inpatient surgeries for repair, that is on page 5 of your policy on the schedule, um.
[CUSTOMER][NEUTRAL] Mhm, I'm looking at it.
[AGENT][NEUTRAL] What's, OK, OK. Um, let's see. Um, now, when he starts physical therapy, we'll need those bills and you, you can submit for the physical therapy. Um, did he receive crutches or a brace or anything like that for like an appliance?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] It's a walker.
[AGENT][NEUTRAL] OK, he got a walker.
[CUSTOMER][NEUTRAL] A walker.
[AGENT][NEUTRAL] OK. Um, did you submit any type of documentation to show that he was prescribed a walker?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm mm.
[AGENT][NEUTRAL] OK, did you get it from a durable medical equipment facility or did the hospital provide it?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] Mm mm medical.
[AGENT][NEUTRAL] OK, so if you'll submit that bill, um, we can do a consideration for the walker as well.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm not sure if the prosthesis would be payable.
[AGENT][NEUTRAL] Have you already been paid for any X-rays or CTs or anything like that?
[CUSTOMER][NEUTRAL] Um, yeah, when he first went in.
[AGENT][NEUTRAL] OK, OK, all right, so those will be maxed out for this accident, um, so we've already considered those, so I'm not going to look at those. So the only other thing is going to be.
[CUSTOMER][NEUTRAL] What was the
[CUSTOMER][NEUTRAL] What's the 11 on um prosthesis, what is the um one device or the multiple devices?
[AGENT][NEUTRAL] Yeah, that's what I'm gonna look at because I'm interested to know as well if him having because it was a total knee replacement, correct?
[CUSTOMER][NEUTRAL] Yeah yeah.
[AGENT][NEUTRAL] Yeah, OK, so I'm going to see, let's see, we will pay the prosthesis benefit amount if a covered person, it this is saying if they lose a hand, foot, arm, leg, or eye as a result of an accident. So the prosthesis is gonna be like an artificial limb, which he did not receive. He received, I mean, he did get.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Kind of a prosthetic device, but not in the sense of what this is defining a prosthesis as. So we wouldn't be looking at that benefit.
[AGENT][NEUTRAL] So we'll just need the walker bill from your DMA store, um, and then we'll need any bills for physical therapy um to be able to consider those and let's see, I.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] And what about home health?
[AGENT][NEUTRAL] Yeah, that's what I was gonna look and see.
[AGENT][NEUTRAL] Where that is at if it's on here at all, let's see.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I did see something and then I did see something for anesthesiologist.
[AGENT][NEUTRAL] Yes. So the anesthesia is a percentage of the, um, well, let me double check your anesthesia benefits here. Make sure they don't apply to just one particular, yeah. So general anesthesia is 25% of the surgery. So it would be.
[AGENT][NEUTRAL] I wonder if it applies to the other inpatient surgeries cause that, I feel like it would.
[AGENT][NEUTRAL] I feel like it would. Um, I'll double check that in just a second. I don't see home help.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Ambulance, ER urgent care physician's office.
[AGENT][NEUTRAL] And then appliance prosthesis, home modification.
[AGENT][NEUTRAL] Yeah, I don't see that you have any type of home health.
[AGENT][NEUTRAL] Coverage. Um, all I see is the physical therapy in regards to what he has been or is going to be receiving.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let me look at that anesthesia real quick as well. I think I'm pretty sure it'll apply. Um, let's see, we will pay a benefit for each day, a benefit amount is payable under the inpatient surgery benefit and covered and the covered person for which the inpatient surgery benefit was payable. So yes, so 25% of the inpatient surgery benefit will be paid as anesthesia.
[CUSTOMER][NEUTRAL] OK, so what does that mean, basically?
[AGENT][NEUTRAL] So, so basically, if I'm looking at everything correct and we pay the other inpatient surgery for repair benefit, which is $300 what we do is we then take $300 and for anesthesia, we take 25% of that. So for anesthesia, there would be a $75 benefit.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So you've got the $300 plus the 75 that is possible payment here, um.
[AGENT][NEUTRAL] And my system just shut down. Um, I believe your hospital admission was 12:50.
[CUSTOMER][NEUTRAL] Hospital
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] OK, and then uh like I said, my system just shut down. I don't know why, so I don't have your policy pulled oh there it is.
[CUSTOMER][NEUTRAL] And then they have the um
[AGENT][NEUTRAL] OK, uh, so the Walker would be another 125 once we get that bill?
[AGENT][NEUTRAL] And then um once the PT begins, that's $50 per, I believe it said, yeah, $50 per visit. Let me see how many visits he gets.
[AGENT][NEUTRAL] Uh let's see.
[AGENT][NEUTRAL] Uh, physical therapy.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Uh, within 90 days, within 365 after the accident, OK, this benefit is payable up to 10 days per plan year. So up to 10 days, so that's an additional $500 if he does, if he needs and does the full 10 days, which with a total knee replacement, I'm assuming he probably will my mom.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Now, what about them?
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] What about the inpatient that I mean they're coming to the house right now.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I don't know that there is. I'm trying to see. I can't.
[AGENT][NEGATIVE] I'm not seeing a benefit for the home health services, um.
[AGENT][NEUTRAL] I'm gonna look through here again just to make sure I didn't overlook anything.
[CUSTOMER][NEUTRAL] you
[CUSTOMER][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] Yeah, I don't see anything for home health services, however, if you want to submit that bill so that we can review it and see if there's anything on there that would qualify under your benefits we absolutely will, um, but I don't see anything for home health, um, so that particular type of benefit I'm gonna go ahead and say is not something that we can consider because I don't see it on your schedule.
[CUSTOMER][NEUTRAL] I'm
[CUSTOMER][NEUTRAL] That surgery.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let me double check and make sure there's not any amendments that I'm missing under your policy that would include home health.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Definitions.
[AGENT][NEUTRAL] Yeah, I don't see any changes so um I don't see a benefit specific to home health. So if there is a payable benefit, it's not gonna come across as a home health benefit. There may be a possibility that um the physical, if he's receiving physical therapy in the home that we could consider that because he is receiving it.
[AGENT][NEUTRAL] Um, let me double check that it doesn't have to be like in a physical therapy facility that it can be essentially just prescribed, um, because obviously, it is.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I remember my mom
[CUSTOMER][NEUTRAL] And that's, and that's on what I just sent.
[AGENT][NEUTRAL] Mhm, um, let's see, a healthcare professional.
[AGENT][NEUTRAL] Perform services which are allowed by their license, practices according to that, treatment by physical means, hydrotherapy, heat, or similar modalities, physical agents, biomedical and neurophysiological principles and devices such therapy is given to relieve pain, restore function and prevent disability following injury. So that's the definition of the physical therapy. And I don't think the benefit limited where that could take place, just that.
[AGENT][NEUTRAL] It was something that is a payable benefit if received so I'm gonna confirm that really quick and we could go ahead and be considering that if not, um.
[AGENT][NEUTRAL] Each day a covered person receives physical therapy from a physical therapist in such individual's office or clinic. Yeah, so it's saying that it does have to be in the office or clinic as a result of a covered accident.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So, as of right now, I don't see anything for the home health services, physical therapy or otherwise. That does not mean that what is on the [PII].
[AGENT][NEUTRAL] May not be able to be considered under something it's just strictly looking at your policy. I don't see anything payable at this time, so we will absolutely review that and see if there is anything, um, but the physical therapy does indicate that it has to be at the physical therapist office or clinic, um, so that kind of takes away from the home health, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm not sure, it depends on the bill, so we'll review that bill there is a possibility that we'll be able to actually consider that but without looking at the bill in depth and looking at all the codes and stuff like that, that one's kind of a hit or a miss right now strictly based on your policy language, OK?
[AGENT][NEUTRAL] Um, but once he starts receiving the outpatient physical therapy, I know for sure we'll be able to consider that whether or not we're able to consider this, what he's received already, um, that one again without looking at your bill, um, I can't say for certainty at this time.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so it just basically who's the claims person.
[CUSTOMER][NEUTRAL] And if, how they're looking at it, right?
[AGENT][NEUTRAL] Yeah and like I said, uh, a lot of these claims go through the auditors myself and there's there's 3 others, um, so we do review a large part of these claims, um, especially when they're going to pay more than a certain amount.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] um we we review them and make sure that nothing's been missed or nothing's been you know overpaid or underpaid or anything of that nature so there is the likelihood that this will go through one of us um prior to being released for payment um so.
[AGENT][NEUTRAL] You know, we'll, we'll double check it, um, but yeah.
[AGENT][NEUTRAL] They'll they'll look at everything they'll.
[CUSTOMER][NEUTRAL] And what's the
[AGENT][NEUTRAL] Sorry, go ahead.
[CUSTOMER][NEUTRAL] One other question. I'm sorry, what's the knee except patella?
[AGENT][NEUTRAL] That's
[AGENT][NEUTRAL] Um, so that one is going to fall up under, I believe.
[AGENT][NEUTRAL] Let's see process.
[AGENT][NEUTRAL] Because I did see that.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] Where was that?
[AGENT][NEUTRAL] Collarbone, rib.
[AGENT][NEUTRAL] OK, so kneecap and then parentheses patella, is that the one you're looking at? That's the 2250?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so that falls up under the um.
[AGENT][NEUTRAL] What does that fall up under?
[AGENT][NEUTRAL] Knee except [PII]. OK, I see that and that one's a $9000. So that's up under your dislocation benefits.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So if his knee had been dislocated and they went in to do a surgical reduction or correction to his knee, um, that would have fallen up under there. And then a little further down, there's going to be similar.
[CUSTOMER][NEUTRAL] That's what they did, they did a.
[CUSTOMER][NEUTRAL] They did a, that's what they did. They um
[AGENT][NEUTRAL] It was a reduction
[CUSTOMER][NEUTRAL] No, um,
[CUSTOMER][NEUTRAL] Not a reduction. What was the other word you said?
[AGENT][NEUTRAL] Like a correction?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, a correction.
[AGENT][NEUTRAL] So he didn't have his knee replaced with metal. He just had his ligaments and stuff corrected?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, do you happen to have.
[CUSTOMER][NEGATIVE] So what happened was, so let me, so what happened was he had a knee replacement 3 years ago, right? He fell. And when he fell, he bust, it bursted and broke the knee, fake kneecap or whatever you wanna call it.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Oh.
[AGENT][NEGATIVE] So it broke his device that was already in his knee.
[CUSTOMER][NEUTRAL] So that's what happened there.
[CUSTOMER][POSITIVE] Exactly, right.
[AGENT][NEGATIVE] Oh dang. He fell hard.
[AGENT][POSITIVE] My goodness.
[CUSTOMER][NEUTRAL] Yeah, and then.
[CUSTOMER][NEUTRAL] Girl, he's been, he's been through it. Like the doctor, the doctor, like 2 years ago told him he was having muscle spasms and his aortic dissection ruptured.
[AGENT][NEUTRAL] Ah
[CUSTOMER][NEUTRAL] You have to go through that kind, that surgery.
[AGENT][POSITIVE] Goodness gracious. Mr. [PII], I'm gonna need you to sit down and chill out, sir.
[CUSTOMER][NEUTRAL] He's had it with.
[CUSTOMER][NEUTRAL] That's what, so yeah, so that's what it was.
[AGENT][POSITIVE] Oh my goodness.
[CUSTOMER][NEUTRAL] It's, yeah, it, it, yeah, it was just this and that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, do you happen to have anything from the surgeon that shows the actual surgical code that they used? Because like I said, we have the billing, we show that he had surgery on his knee, but we don't have a surgical code for what that surgery was. All we have is an X-ray and like the hospital bills.
[CUSTOMER][NEUTRAL] So I don't know if you're putting all this in.
[AGENT][NEUTRAL] And they don't put the actual code on there.
[CUSTOMER][NEUTRAL] Mm mm, well, you should have um with Doctor [PII] sent, he sent his physician statement and I know he put codes on there.
[AGENT][NEUTRAL] Did he? OK, let me double check that.
[AGENT][NEUTRAL] Let me see if there's a surgical code on there for that.
[AGENT][NEUTRAL] Cause I saw the diagnosis, but I didn't see, let's see, left total knee replacement.
[AGENT][NEUTRAL] Uh, what is that word?
[CUSTOMER][NEUTRAL] I know, I'm just taking you through it, huh.
[AGENT][POSITIVE] No, no, no, it's OK. I mean I wanna make sure I answer all your questions and that we, we indeed have what we need, um, because I don't want you missing out on anything. OK, let's see.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] 4 left total knee.
[AGENT][NEUTRAL] Replacement.
[AGENT][NEUTRAL] OK and.
[AGENT][POSITIVE] I think that's OK.
[AGENT][NEUTRAL] Good old doctor's handwritten.
[AGENT][NEUTRAL] OK. Total knee arthroplasty with or without patellar resurfacing unilateral.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I do have a code.
[AGENT][NEUTRAL] I'm gonna highlight this and
[AGENT][NEUTRAL] Put
[AGENT][NEUTRAL] What that CPT is.
[AGENT][NEUTRAL] And we'll have to review that uh.
[AGENT][NEUTRAL] I would have to
[AGENT][NEUTRAL] Look up
[AGENT][NEUTRAL] The details of the surgery to see if we could put it up under.
[AGENT][NEUTRAL] Because like I said, it's still showing just as a knee replacement. It's not showing as a repair of his tendons or ligaments or because it was dislocated or fractured or anything like that. It's just showing as a knee replacement. Um, and even the diagnosis code used is not indicative of a fracture. It's showing that he had
[AGENT][NEUTRAL] An issue with his already orthotic device that was implanted before, which is going to be where he had that knee replacement previously. So it's not, you know, it's not showing as a fracture, which it's probably not going to because it's not a bone. It's, you know, a device. Um, but
[AGENT][NEUTRAL] I think some research on either my part or the examiner or both are gonna have to be done regarding that.
[AGENT][NEUTRAL] Procedure. Um, well, that's the previous condition. Describe the previous condition. OK.
[AGENT][NEUTRAL] He didn't put a code for the recent condition.
[AGENT][NEUTRAL] It is due to an accident.
[AGENT][NEUTRAL] Not permanent.
[AGENT][NEUTRAL] OK, so he put the code and information for the previous condition. He did not provide information or a code on his recent, like his current surgical need. So if you have.
[AGENT][NEUTRAL] A surge like an operative report, did you submit that in the medical records by chance? Does it was the operative report part of that? OK, let me look at that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah. Mhm.
[AGENT][POSITIVE] I just love it when you guys cover all the bases because then every question it's like yep it's there and I'm like OK perfect let's go look at it.
[CUSTOMER][NEUTRAL] But yesterday when I talked to her, she looked at it and she said everything is, she said everything is here. I don't know why they denied it.
[AGENT][NEUTRAL] Let's get this answered.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, so truthfully when I was looking at it we had um.
[AGENT][NEUTRAL] We had.
[AGENT][NEUTRAL] You know, proof that he was impatient because there was room and board.
[AGENT][NEUTRAL] Um, so I don't know why exactly we would have, um,
[AGENT][NEUTRAL] Requested
[AGENT][NEUTRAL] Like admin and discharge because there was room and board charges and that typically is sufficient for paying um that much of it.
[AGENT][NEGATIVE] Um, what did we pay? Have we paid anything? No, we've paid stuff from February, but we haven't paid anything for.
[AGENT][NEUTRAL] For this, obviously, because it just took place. So, um,
[AGENT][NEUTRAL] I'm, I'm not certain.
[AGENT][NEUTRAL] Why that wasn't already considered truthfully, um.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] That I guess that's why I'm trying to be like, OK, do we have notes here that kind of like.
[AGENT][NEUTRAL] Go into what happened because I say [PII].
[AGENT][NEUTRAL] [PII], like all of his past, so I'm sifting through this again to see if I have.
[AGENT][NEUTRAL] Something from the physician about this surgery. I feel like we probably could have at least went forward with the admission and everything. My only assumption is they saw something that they felt like they needed more information for. I can't speak to their mindset when they were looking at it. Um.
[AGENT][NEUTRAL] So I don't know, um, maybe because the billing just didn't have a diagnosis code on it, possibly. Um, I know that that physician statement was submitted, so.
[AGENT][NEUTRAL] I, I, I can't speak to it, Miss [PII], honestly, like there's a part of me that's like, oh yeah, we could have paid and then there's the other part of me that's like, OK, you know this examiner has been with the company for quite some time. There has to be a reason. What that reason is. I'm not 100% because there's not any notes on here as to why it wasn't paid and they felt like they needed more information so I'm not 100% on that, um.
[CUSTOMER][NEUTRAL] Is it going back, is it going back to the same examiner?
[AGENT][NEUTRAL] Yes, it will go back to the same examiner so they will have the information that they requested.
[CUSTOMER][NEUTRAL] And then um another question is the code that you put on there, Doctor [PII], what was that code for?
[AGENT][NEUTRAL] So the code that he made um notation of was his previous knee replacement.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] It was not for the current issue.
[AGENT][NEUTRAL] Um, because, so the question on that form says has essentially have they had this a similar problem previously. He indicated, yes, that it was like way back in [PII], and then he put what that condition was and so he did put that there was a total knee replacement at that time. So that's what he was referencing is what was, when did they previously have this issue and what was it?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so there is no information regarding what they did this time other than the diagnosis and he did put that um but he didn't put.
[CUSTOMER][NEUTRAL] And what was that?
[CUSTOMER][NEUTRAL] What was the diagnosis?
[AGENT][NEUTRAL] What was
[AGENT][NEUTRAL] Um, it was
[CUSTOMER][NEUTRAL] are you looking at the cause he sent them to it, you looking at the one from last week?
[CUSTOMER][NEUTRAL] That is fine.
[AGENT][NEUTRAL] Um, so the one, yeah, so the one that I have is from, let me double check that it was from last week.
[AGENT][NEUTRAL] Let's see, yes, we received it on [PII].
[AGENT][NEGATIVE] That would have been last week, right? Yeah, yeah, so we received it on [PII] and the code says other mechanical complications of other internal orthotic device or implant.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that is what that is for.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So we have the diagnosis. We just don't have his surgical code for this surgery that he just did.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, so.
[AGENT][NEUTRAL] I'm trying to see if it was noted in these records as well um.
[AGENT][NEUTRAL] Surgery risk.
[AGENT][NEUTRAL] Surgical history.
[AGENT][NEUTRAL] Status post bilateral knee replacement a few years ago. [PII] had had more problem. He had some stiffness, revised of the tibia, was doing OK until the past few months.
[AGENT][NEUTRAL] And he was here for revision surgery.
[AGENT][NEUTRAL] So he was there for a revision, obviously not because he was just having issues. It was as the result of his fall he was needing the revision.
[AGENT][NEUTRAL] Um, but we have, we have information from the physician that shows that this was an issue because of the fall, so I don't feel like that's.
[AGENT][NEUTRAL] of concern.
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] Medications.
[AGENT][NEUTRAL] Bottle sounds.
[AGENT][NEUTRAL] Plan.
[AGENT][NEUTRAL] Uh, benefits and other options for treatment, consented to surgical intervention, failed right knee, pre-op workup appears negative for infection. OK.
[AGENT][NEUTRAL] And then that's discharge medication.
[AGENT][NEUTRAL] OK, mechanical complication of internal orthopedic device implant craft initial encounter.
[AGENT][NEUTRAL] Medic medications.
[AGENT][NEUTRAL] And then this was just talking about follow up.
[AGENT][NEUTRAL] For his.
[AGENT][NEUTRAL] Physician.
[AGENT][NEUTRAL] OK, and then the continuing care for home health.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Like lab work.
[AGENT][NEUTRAL] General anesthesia information.
[AGENT][NEUTRAL] So just doing a run through of.
[AGENT][NEUTRAL] What was submitted.
[AGENT][NEUTRAL] The surge, it says that he's there for a revision. Um.
[AGENT][NEUTRAL] Let's see CPT 4.
[AGENT][NEUTRAL] I'm gonna put knee revision and see what that pulls.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] OK, so I do have a code and it says this code is used when a previously implanted knee prosthesis needs to be revised or corrected.
[AGENT][NEUTRAL] Um, it specifically covers the femoral and entire tibial component of the revision.
[AGENT][NEUTRAL] So that sounds about like what I'm reading here. There's not an actual code, but based off of the information that's kind of sprinkled throughout these records and based off of that um physician statement, that kind of sounds like what's going on.
[AGENT][NEUTRAL] Um, I think that's still going to fall up under our, um, inpatient other surgery benefit. I don't think because it is not a bone that um was
[AGENT][NEUTRAL] The issue, um.
[AGENT][NEUTRAL] That it's a device that was the issue that was previously implanted. I don't think that we're gonna have any qualifications for fracture or dislocation benefits um if you have information that would contradict that thought, please feel free to submit it, um, because we could be totally wrong on that.
[CUSTOMER][POSITIVE] Perfect
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah. So if you have an actual code for the surgery or if you have
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] Like an operative report where they go in and just draw out everything that they did because like I said the only thing it says is that he was there for a revision we have the, the report that says um you know.
[AGENT][NEUTRAL] Cause it says revision arthroplasty knee. That's all it says. Left knee revision, so far, no evidence of infection. You know, it, it doesn't say anything about a fracture, a dislocation, ligaments having to be corrected. It doesn't say any of that. It's strictly talking about fixing his device, his implanted device in his knee. So if you have any information.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Other than that, please feel free to submit that. We will absolutely consider other benefits. We just don't have enough to do that at this time.
[CUSTOMER][NEUTRAL] Now, when is this going to be adjuster?
[AGENT][NEUTRAL] Um, we ask from the date of receipt to allow 7 to 10 business days. Um, it does get processed sooner on occasion. Um, we just ask that you allow us that amount of time because it depends on the volume of claims that have been received, so it could be processed sooner, but we do ask for at least 7 to 10 business days so I would say it would probably be pulled for review by next week.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alrighty then well thank you so much.
[AGENT][NEUTRAL] You're welcome. If you have any other questions, please give us a call, OK?
[CUSTOMER][POSITIVE] I sure will. Thank you. Have a good day. Bye.
[AGENT][POSITIVE] OK. You're welcome. Yes, ma'am. You too.
[CUSTOMER][NEUTRAL] Bye-bye.
[AGENT][NEUTRAL] Bye-bye.