AccountId: 011433970860
ContactId: 35fcef5a-c903-4570-8da4-f791c07b332c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 469170 ms
Total Talk Time (AGENT): 142285 ms
Total Talk Time (CUSTOMER): 321940 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/35fcef5a-c903-4570-8da4-f791c07b332c_20250225T21:23_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling American Public Life. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. I'm trying, I'm filing claims that we have, uh, the policy, um, and I keep getting kickbacks. I need you to help me figure out what's going wrong with filing a particular my dependent claim.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so I, I said, what it is, I'll give you the, the brief rundown. So he had, he went to a surgeon. He had a felt a hernia. He went to a surgeon. I'm pretty sure he might have self-paid. He was [PII]. He didn't know what to, you know, he has insurance, but I'm not sure. But, so bottom line is the first kickback, it said I need notes from the doctor ordering the CAT scan. So I provided, they finally got me the notes. I provided that. I have the correct code.
[CUSTOMER][NEUTRAL] Um, and I don't know what's missing, so there's many different confirmation numbers because, you know, I don't, maybe they haven't merged them together and the most recent, uh, denial or zero balance require we're requesting more information. I only see one page of the reason because I try to find it online before it comes in the mail so I can get.
[CUSTOMER][NEUTRAL] Because it takes a while back and forth with these doctors. Anyway, so uh yesterday there was something, um, that I can only see page one and it has the doctor's name, but so I, the CAT scan was done at a different facility, you know, he ordered the CAT scan, we paid $400 for the CAT scan. I've got the statement, billing statement, codes for that. So I don't know what's missing.
[AGENT][NEUTRAL] OK, may I have your policy number and I'll pull it up.
[CUSTOMER][NEUTRAL] Policy number, I think it's on these claims, 1,807,330.
[AGENT][NEUTRAL] May I have your first name and a good callback number?
[CUSTOMER][NEUTRAL] My name is [PII] [PII].
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Mhm. I'm looking at two different dates of service. One was, of course, the initial doctor's visit, and then the second one was, of course, the CAT scan and the then the radiologist who read the CAT scan.
[AGENT][NEUTRAL] Thank you. Can you verify your date of birth, your mailing address, and your email, please?
[CUSTOMER][NEUTRAL] Mine [PII]. Phone email is uh I'm not sure if it's [PII] or [PII]. I'm not sure which.
[AGENT][NEUTRAL] Thank you for verifying that information. Please be advised that verification of coverage does not guarantee the payment of a claim. Is the claim for yourself or your son?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] No, it's for my dependent, my son [PII]. The dates of service are [PII] and [PII]. And again, it's, it's hard sometimes to get this stuff from the doctors.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I'll pull it up.
[AGENT][NEUTRAL] OK, let me get this pulled up one moment.
[CUSTOMER][NEGATIVE] So the first denial said we need doctor's notes which I provided and then it got denied again but I can't see the reason why I only it only shows one page on the file.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Codes 1 and 2, but I don't know what those mean.
[AGENT][NEUTRAL] OK, so for [PII], it looks like.
[AGENT][NEUTRAL] We're asking for the diagnosis code.
[CUSTOMER][NEUTRAL] I think I provided that, didn't I?
[AGENT][NEUTRAL] OK, let me get it pulled up. Sometimes we get the CPT code in place of a diagnosis code. Let me just verify it.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] It was just an abdominal CAT scan without contrast.
[AGENT][NEUTRAL] Yes, that's what it looks like uh 1656.
[CUSTOMER][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Let me see, I have my notes here.
[CUSTOMER][NEUTRAL] ATT correlation PT code on [PII], I gave you something and from the doctor's office.
[AGENT][NEUTRAL] OK, this was [PII].
[CUSTOMER][NEUTRAL] Yeah, I'm looking at the code 74176. I provided that.
[CUSTOMER][NEUTRAL] And it also was the statement, the billing statement.
[AGENT][NEUTRAL] CPT code 74176 and the diagnosis code would be the reason for the ultrasound.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's what the that's what the
[CUSTOMER][NEUTRAL] Would that be on the doctor's notes?
[AGENT][NEUTRAL] Yes, and there's
[CUSTOMER][NEUTRAL] So I don't need a CP code. I need a, a diagnosis code.
[AGENT][NEUTRAL] Correct. The diagnosis code is the reason.
[CUSTOMER][NEUTRAL] Is that like 120, is that like 120.4, you know, I'm just saying, is it like that kind of number?
[AGENT][NEUTRAL] Yes. Yes, ma'am.
[CUSTOMER][NEUTRAL] So I need a diagnosis. So that's what I'm missing is a diagnosis code.
[AGENT][NEUTRAL] Diagnosis code, yes.
[CUSTOMER][NEUTRAL] That's all I'm missing from which doctor? The initial doctor he met with? From Doctor.
[AGENT][NEUTRAL] Yes, if.
[AGENT][NEUTRAL] If this radiology can give it to you.
[CUSTOMER][NEUTRAL] Sometimes the clerks don't know which is which. I'm sorry?
[AGENT][NEUTRAL] Yes. If the provider at this uh radiology consult can give it to you, whoever can give you the diagnosis code, but the diagnosis code is the reason for your services.
[CUSTOMER][NEUTRAL] Cause he had a hernia. OK. Um.
[CUSTOMER][NEUTRAL] Let me see if it's on the notes. Let me just see if he wrote it. I doubt it because the doctor scribbled all this stuff.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] Cause it's hard to read diastasis, CT scan, X-ray, blah blah blah.
[CUSTOMER][NEUTRAL] Um, they said they need a doctor's note, so I'm missing a diagnosis code specifically.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Who would have that, the place who did the um CAT scan or the doctor that ordered the CAT scan?
[AGENT][NEUTRAL] The doctor that ordered the CAT scan should be able to provide it.
[CUSTOMER][NEUTRAL] Ordered it should know a diagnosis code. OK, but it is it it, so that's all I need to do. So if I get this from him, I can just upload or call. Can I call and give you the number?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] They can't take them over the phone any longer. They have to be in writing. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I just have to I just can send this note and put a sticky across it and put the diagnosis code on it once I find what it is. OK, so that's all I'm missing and now will that also cover the $69 some odd dollars that the um radiologist billed to to read it.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] You see, there's, there's a $400 charge, and I know you don't pay for office visits, but, and then there's a $69 some odd dollar for the radiologist who actually read the CAT scan.
[AGENT][NEUTRAL] I like
[AGENT][NEUTRAL] Let me see what these benefits allow.
[AGENT][NEUTRAL] And this was outpatient, correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] So it looks like 7500 is the benefit amount. Let me get this pulled up.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm. Yup.
[CUSTOMER][NEUTRAL] Yeah, I know he's allowed it. There's just, you'll see a second and I provided that to you guys that has this.
[AGENT][NEUTRAL] And he
[AGENT][NEUTRAL] He has not met his [PII], so yes, he should be good.
[CUSTOMER][NEUTRAL] The 6976. So that, when I get the diagnosis code, that should cover the radiologist reading it too. That was a separate doctor. Of course, you never meet them. They're behind the scenes, you know what I mean? So they're behind a wall, and you don't pay them. You just paid the hospital that. So, OK. So I need to call back the guy who ordered the CAT scan and ask him for the diagnosis code, and then send it to you. OK.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes, and for the one on 9-17-2024, we're asking for the primary insurance explanation of benefits on that one.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Well, which one? Say it again?
[AGENT][NEUTRAL] 917 2024.
[CUSTOMER][NEUTRAL] I think I should.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, I'm 2024, you need the um EOB explanation of that, that, OK, that was the initial doctor's visit. I know I provided that probably um.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I know I provided that. Let me see if I can find that date.
[CUSTOMER][NEUTRAL] EOB Well, either way, I, I'll provide it again. So I need the EOB and you need the diagnosis code from the doctor that he met with.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Correct. OK. I will, I will get going on this and get, so that's what's holding me up. OK. Thank you. Yup, bye, bye.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] [PII], you're so welcome. Thank you for calling American Public Life. Have a great day. Bye-bye.
[CUSTOMER][POSITIVE] Thank you you too bye.
[CUSTOMER][NEUTRAL] Those