AccountId: 011433970860
ContactId: 380c66e7-b043-4dec-bb4f-a8a0c23d6208
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1023390 ms
Total Talk Time (AGENT): 376735 ms
Total Talk Time (CUSTOMER): 197245 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/380c66e7-b043-4dec-bb4f-a8a0c23d6208_20250103T17:26_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. Good morning. My name is [PII] and I'm calling for provider's office to check the claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status, [PII]. May I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, that is [PII] no extension.
[AGENT][NEUTRAL] Thank you and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] So totally uh with two claims.
[AGENT][NEUTRAL] 2? OK. And may I have the first number?
[CUSTOMER][NEUTRAL] And hold on, I'm sorry.
[CUSTOMER][NEGATIVE] Totally 3 claims.
[AGENT][NEUTRAL] May I have the first member's policy number?
[CUSTOMER][POSITIVE] Sorry for that.
[CUSTOMER][NEUTRAL] So, that is 01665298.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, that is [PII].
[AGENT][NEUTRAL] You said the policy number is 10166. Hold on one second.
[AGENT][NEUTRAL] I typed that wrong, my apologies.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] OK, can you verify [PII]'s date of birth for me, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] [PII]. Belamontes.
[CUSTOMER][NEUTRAL] 2 $29 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yes, that is 2 page Medical Group.
[AGENT][NEUTRAL] OK, 5.
[AGENT][NEUTRAL] OK, here we go. So I'm showing we received the claim on
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That claim number is 348.
[AGENT][NEUTRAL] 4045.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, because office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] Is it not cover not covered in the patient plan or plan?
[AGENT][NEUTRAL] The patient's policy.
[CUSTOMER][NEUTRAL] Can you get the cash plan type?
[AGENT][NEUTRAL] Sorry?
[CUSTOMER][NEUTRAL] May I know the patient plan type, please?
[AGENT][NEUTRAL] Yes, this is a Medlink policy. Is there supplemental gap insurance?
[CUSTOMER][NEUTRAL] OK, uh, and just for the information, office visit it is a basic, uh.
[CUSTOMER][NEUTRAL] Thing right then why that is not covered on the patient plan also I can see that on [PII] offices it is.
[CUSTOMER][NEUTRAL] Already paid
[AGENT][NEUTRAL] OK, hold on one second.
[AGENT][NEUTRAL] So you're wanting to know why office visits are not covered on the policy and you're stating the [PII] claim was paid on?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so the so the insured has the office treatment rider. So the treatment in the office as long as it's not cosmetic, can be covered by the policy. If this is for a facility charge, there would be no coverage because there's no in-office setting coverage, only the treatment. So let me look at the [PII] claim and see what the difference is. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, uh, this one, the one that you're calling in reference to, that one was billed as a
[AGENT][NEUTRAL] Um, an office visit, 99214, that's a place of service. Let me look for the Maye.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It was the May bill, um, what was the total bill on that [PII]?
[CUSTOMER][NEUTRAL] Same amount of $29 even.
[AGENT][NEUTRAL] OK, I'm actually showing this claim was denied also, um, claim number 347-0862 was denied because office visits are not covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, but for [PII] we build the place of service 11 only. That is service is that right?
[AGENT][NEUTRAL] Yes, that's place of service for an office visit.
[CUSTOMER][NEUTRAL] Then why the claim is not covered under the pension plan?
[AGENT][NEUTRAL] Because office visits are not covered by the policy, the treatment is. There's a difference in the coding. If you use 99214, 99213, those are place of service codes. If you use um like a procedure code or something, that's a treatment. So the treatment in the office can be covered, but the facility charge or the office visit itself is not covered.
[CUSTOMER][NEUTRAL] OK, no problem. I request you to send the UB through fax.
[AGENT][NEUTRAL] Sure, what's a good fax number for you that I can send? Did you want the original one or the May or both?
[CUSTOMER][NEUTRAL] The original one, the one, the [PII]. The fax number going to be [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And should I put attention [PII]?
[CUSTOMER][NEUTRAL] That is [PII].
[AGENT][NEUTRAL] OK, and that fax number was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Alright, I'll go ahead and fax this explanation of benefits over to you now. Was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] No, and I have 2 more clients, so the next one is going to be same patient.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Oh, it's this, so this are the other two claims for the same member?
[CUSTOMER][NEUTRAL] No, the next one only same patient and the last one will be different patient.
[AGENT][NEUTRAL] OK, what's the next date of service?
[CUSTOMER][NEUTRAL] [PII] to $29 even.
[AGENT][NEUTRAL] [PII] $229.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], OK.
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] $229.
[AGENT][NEUTRAL] OK, so for that claim we received on [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That claim number is 349.
[AGENT][NEUTRAL] 7256.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Ends on
[AGENT][NEUTRAL] Hold on one second.
[AGENT][NEUTRAL] 57.
[AGENT][NEUTRAL] Sorry, I lost my place. Hold on one moment.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] Sorry, another screen popped up while I was looking at the claim, and on [PII], the claim was denied because office visits are not covered on the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, great. So same scenario and you're going to send the UB the same fax number, same attention. Thank you. Can I get the call reference number for this patient?
[AGENT][NEUTRAL] Sure, so the call reference number for the whole call will be my name and today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] So your name is [PII], right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Thank you and are you ready for the last member ID?
[AGENT][NEUTRAL] Um, hold on one moment. I'm sending these faxes to you for this number.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so I just sent the first one over to you. I'm getting ready to send the second one now. Um, do you mind if I place you on just a brief hold?
[CUSTOMER][POSITIVE] Yes, take your time.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] Why is my stuff going so slow? Come on.
[AGENT][NEUTRAL] What's the first one.
[AGENT][NEUTRAL] The 2nd 1.
[AGENT][NEUTRAL] Oh man, this is crazy.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, so I just did the 2nd 1.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello that room.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So I've sent over both explanations of benefits for you. So you should be receiving that shortly. And then what's the last member's policy number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yes, thank you so much for that. And the last number is 01665298.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, that is
[AGENT][NEUTRAL] I'm sorry, do you mind if I place you on just a brief hold? My computer just glitched.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Well, take your time.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Right. Thank you so much for holding. I apologize for that wait. And can you verify the, actually, this is the same policy number as the other member. Which member are you calling in reference to for this claim?
[CUSTOMER][NEUTRAL] Actually this is for patient [PII].
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] The patient name is [PII].
[AGENT][NEUTRAL] That's, can you spell the first name for me, please?
[CUSTOMER][NEUTRAL] Yeah, that is [PII].
[AGENT][NEUTRAL] And what's the date of birth?
[CUSTOMER][NEUTRAL] That was [PII].
[AGENT][NEUTRAL] OK. So I have her here and thank you for verifying. And may I have the date of service for the claim?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the total bills?
[CUSTOMER][NEUTRAL] Yeah, that one is going to be.
[CUSTOMER][NEUTRAL] $95 even.
[AGENT][NEUTRAL] 95
[AGENT][NEUTRAL] OK, hold on one moment. And again, just for the call, all the information provided is a verification of benefits, not a guarantee of payment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] So I'm showing we received the claim on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That claim number is 345.
[AGENT][NEUTRAL] 651-7.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim to the provider.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] A total of $5.30.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Did you need the check information?
[CUSTOMER][NEUTRAL] Yes, and that is not in on this claim, right?
[AGENT][NEUTRAL] Um, code 80053 was denied. Let me give you that reasoning. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, benefits are payable benefits not payable for conditions other than sickness or injury.
[CUSTOMER][NEUTRAL] So we may not go on the patient plan this one also.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Are you sure the CPT code is not covered under the patient plan?
[AGENT][NEUTRAL] Yes, I'm sure. Um, procedure code 80053 is not, is not a sickness or injury.
[AGENT][NEUTRAL] So that is why it's not covered under the patient's policy.
[CUSTOMER][NEUTRAL] OK, and the patient plan type is meddling policy, right?
[AGENT][NEUTRAL] Right, this is their Medlink supplemental gap insurance.
[CUSTOMER][POSITIVE] OK, got it. And this one also, are you going to send the be through same fax number, same attention. The call driver's number will be your name and today's date, and that's all for today. Thank you so much for asking. Have a wonderful day.
[AGENT][POSITIVE] Yes, I can send this fax for you.
[AGENT][POSITIVE] You also, and thanks for calling APL. Have a great day.