AccountId: 011433970860
ContactId: 3b4cd9f7-ab4c-4bf5-b9fa-12fad4ff2e68
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 602280 ms
Total Talk Time (AGENT): 224008 ms
Total Talk Time (CUSTOMER): 346762 ms
Interruptions: 4
Overall Sentiment: AGENT=0.5, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/03/3b4cd9f7-ab4c-4bf5-b9fa-12fad4ff2e68_20250203T19:10_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh yeah. Hi. My name is [PII]. I'm calling from provider's office. I'm looking for a claim denial reason. Uh, could you please help me with that?
[AGENT][NEUTRAL] Yes, I can check on the claim for you [PII]. uh, can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] Yeah, sure. It's [PII] and this is my direct line.
[AGENT][NEUTRAL] OK, thank you. Do you have the policy number?
[CUSTOMER][NEUTRAL] Yeah, of course. Uh, it's actually 02137789.
[AGENT][NEUTRAL] OK, thank you. And uh what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] Uh first name is [PII], and last name is uh [PII]
[AGENT][NEUTRAL] OK, do you have the date of birth? Mhm.
[CUSTOMER][NEUTRAL] And the date of birth is [PII]. Yeah, [PII].
[AGENT][POSITIVE] Perfect, thank you for verifying that [PII]. uh, do you have that claim number by chance?
[CUSTOMER][NEUTRAL] Uh, let me check that. And before, can I have your name please one more time for document purpose?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure, it's [PII]
[CUSTOMER][POSITIVE] All right, thank you so much, [PII], um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I think uh claim number we got.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh, signal page.
[CUSTOMER][NEUTRAL] I think I'm not sure. Is this a claim number? It's like 3186294? Is this your claim number?
[AGENT][NEUTRAL] 94, let's see.
[CUSTOMER][NEUTRAL] Yeah, 318 6294.
[AGENT][NEUTRAL] They do typically begin with a 3.
[AGENT][NEUTRAL] OK, give me just a moment.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Yes, OK, and that that date of service that was [PII].
[CUSTOMER][POSITIVE] It's no problem. Take your time.
[CUSTOMER][POSITIVE] Yes, exactly.
[AGENT][POSITIVE] OK, yes. All righty. I did find it. Give me just a moment.
[AGENT][NEUTRAL] Let's take a look. OK, so, uh, we were unable to pay that benefit as office visits are not covered under this policy.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] So office message.
[CUSTOMER][NEGATIVE] But the code 881,000, this is also denied.
[AGENT][NEUTRAL] That one was paid, that was uh $2.23.
[CUSTOMER][NEUTRAL] Oh, that's fine now. So this particular CPT code, the 992138ip code is just covered under the patient's plan, right?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] That's correct, yes, it does not cover office visits.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Just give me a moment, uh, 99213.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Because it looks like usually the tele visit or something like that's not covered. It's, it looks like uh in-person visit. I think it's office visit. It should be covered. Uh, is this provider something is not participating with this plan or something like that or it's procedures not covered under the patient's plan because we got denied like the product does not have a provider participation network benefits have not been reached something like denial we have received.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, um, so this plan is a secondary medical plan, so it is supplemental, um, but it is also dependent on major medical, uh, that being said, it does have its own policy, of course, with, with what it does and does not cover. Uh, some of our policies that are secondary medical do cover office visits. This particular one does not.
[CUSTOMER][NEUTRAL] So, this is, yeah.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] That's not covered. OK. OK. So it's does not covered under patient's plan.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] And what is the patient's plan name by chance do you have a plan name for this?
[AGENT][NEUTRAL] Uh yeah, it's [PII]
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, meddling plan. So according to this plan, I think it's the office seat doesn't cover any type of office receipt, right? Any telet or office receipt, all, all this doesn't cover? OK, all right. So we can bill to the patient regarding this. We can bill to the member.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] We do not say, we don't say what is patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] All right. OK.
[CUSTOMER][NEUTRAL] All right. Can I have a denied date on this claim?
[AGENT][NEUTRAL] Oh yes, one moment, let me take a look.
[AGENT][NEUTRAL] [PII]. OK, uh, so this claim was originally, it was, yeah, yes, so the process date was uh [PII], yes.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, I see the note here somebody. OK, I'll check with this. And uh, also, uh, I need one more from you. What is your timely filing in case you sent an appeal with this, uh, supporting documents? What is the timely filing for appeal?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEGATIVE] Appeals timely filing is 180 days uh from that process date so unfortunately it is outside of that time frame.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] From the
[CUSTOMER][NEUTRAL] Yeah, exactly. So it's state of denied and it's first timely filing.
[CUSTOMER][NEUTRAL] OK, um, and, uh, so if you don't mind, I have another 2 more data service to the same patient. Cou[PII] you please help me with that?
[AGENT][NEUTRAL] Oh, it is the same number? OK, um, give me just a moment.
[CUSTOMER][NEUTRAL] Yeah, same patient.
[AGENT][NEUTRAL] Yes, OK, did you have those claim numbers or did I need to search for the date?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, yeah.
[CUSTOMER][NEUTRAL] No, I think I have a claim number. I will provide that. Just a moment, yeah. Uh, so the claim number, this one is 31, sorry, 32157772.
[AGENT][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] All right. This one looks like it's going to be the same. Um,
[CUSTOMER][NEUTRAL] Same situation?
[AGENT][NEUTRAL] Does look almost identical actually, yes, yes, also we were unable to pay uh that office visit so the 99214 uh, but the 81,000 we were able to pay that $2.23 yes.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's pay.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Ah
[CUSTOMER][NEUTRAL] Because we guys start like I think it's the primary is processed and then left out some deductible to the second responsible. So usually, we guys, we guys expecting like the co-pay or deductible coinsurance. It should be responsible by the secondary. So, but you're saying this particular plan, this type of service is not covered actually, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] That's correct. Uh, this plan is designed to help with co-pay, deductible and co-insurance, but again, it does have its own policy on what is and is not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Are you, are you guys following your own guidelines or is there any primary guidelines you follows, uh.
[AGENT][NEUTRAL] Typical guidelines it would follow as major medical, yeah major the major medical, so whoever the primary is.
[CUSTOMER][NEUTRAL] Any guidelines
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you follow your own guidelines, right?
[AGENT][NEUTRAL] This policy, yes, does not cover office visits.
[CUSTOMER][NEUTRAL] Perfect receipts. OK, alright, particular service. OK, I think this claim number is 321-5772 and it is denied on [PII].
[AGENT][POSITIVE] That's correct, yes.
[CUSTOMER][NEUTRAL] [PII], it's the same thing. So you can't appeal on this express family filing now. So I have a last one more data of service to the same patient. Uh, so that is um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Uh for [PII], uh.
[CUSTOMER][NEUTRAL] I'm sorry, [PII]?
[CUSTOMER][NEUTRAL] And this claim number.
[CUSTOMER][NEUTRAL] It's um.
[CUSTOMER][NEUTRAL] 31634004.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] OK, this one looks like an offices as well.
[AGENT][NEUTRAL] Yes, yes, so this one is also an office visit, uh, that [PII], uh, so we were unable to pay that benefit.
[CUSTOMER][POSITIVE] Yeah, exactly.
[CUSTOMER][NEUTRAL] OK. All right. So this particular meddling plan, it doesn't cover, never cover uh the office visits, right? So any, uh, all right. OK. Because sometimes the plans allows uh uh it's like, uh, it's maybe 3 visits per year or something like that. So you don't have any allowable, right?
[AGENT][POSITIVE] That's correct, yes.
[AGENT][NEUTRAL] Oh yes.
[AGENT][NEUTRAL] Right, right, I see what, yeah, so some of them do offer a specific allowance per calendar year. um, this policy just absolutely does not cover office visits.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] Yeah, exactly.
[CUSTOMER][NEUTRAL] Oh, I got you. OK, that's needed, I think. Uh, so this is the one now. OK, I think is almost done now. So for your future purpose, uh, what is your fax number for appealing in case any other claims, so any fax numbers for appeal, yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] Sure, yeah, so that fax number is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, just make sure [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] attention, do you want any attention in case, uh, in the appeals department?
[AGENT][NEUTRAL] Uh, it would just be the claims department, uh, claims department, yes.
[CUSTOMER][NEUTRAL] Claims department. OK, got you.
[CUSTOMER][NEUTRAL] All right, I think it's almost done now. So I think now the patients from American public, yes, there's no any other patients. So that's it for today now. So can I have any reference number for this call?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, reference number would just be my first name, last initial, and today's date. Uh so my name is spelled [PII] last initial is [PII] Was there anything else I could help you with, [PII]?
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][NEUTRAL] OK, well this
[CUSTOMER][NEUTRAL] Uh-huh. OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] Uh, no, thank you so much for your kind assistance. Thank you. Have a nice day for you.
[AGENT][POSITIVE] Alright, yes, of course, thanks for calling APL you too bye bye.
[CUSTOMER][POSITIVE] Thank you. Bye-bye. Yeah.