AccountId: 011433970860
ContactId: 3de64977-bb98-496c-84be-b4ef3158ddd5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 801729 ms
Total Talk Time (AGENT): 296952 ms
Total Talk Time (CUSTOMER): 198815 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/13/3de64977-bb98-496c-84be-b4ef3158ddd5_20250313T16:29_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, my name is [PII] calling from the provider office, founder of the claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to assist you with the claim status and [PII], [PII], um, may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure. That is [PII].
[AGENT][NEUTRAL] Wait a minute, [PII].
[CUSTOMER][NEUTRAL] 6, yes, [PII].
[AGENT][NEUTRAL] Thank you for that. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] 2
[AGENT][NEUTRAL] OK, may I have the first member's policy number?
[CUSTOMER][NEUTRAL] 60801.
[AGENT][NEUTRAL] So that's our payer ID. Do you have the member's ID card available?
[CUSTOMER][NEUTRAL] No, uh, if you can check with them manually, I can provide you that name and date of birth.
[AGENT][NEUTRAL] OK, and what's the member's first and last name?
[CUSTOMER][NEUTRAL] So the first name is [PII] and the last name is [PII]
[CUSTOMER][NEUTRAL] [PII] I'm sorry, that is [PII]
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So, that is [PII] [PII], [PII] [PII] [PII] [PII], [PII] [PII], [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, so I believe I just located the policy. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, can you verify the member's date of birth?
[CUSTOMER][NEUTRAL] That is [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] [PII], total charges.
[CUSTOMER][NEUTRAL] $631.17.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] AdventHealth respiratory and Equipment.
[AGENT][NEUTRAL] Alright, so I don't show a total bill, a claim on file with the total bill of 63117. Could there be another amount?
[CUSTOMER][NEUTRAL] Uh, so, do you have the, I mean, uh, [PII] for the different, uh, amount?
[AGENT][NEUTRAL] Yes, which is why I'm asking, is there a different amount?
[CUSTOMER][NEUTRAL] Uh, no, I don't have. Uh, can you provide me the, I mean, total charge? My be, it would be, uh, the allowed amount?
[AGENT][NEUTRAL] What's your tax ID?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, so this is a different claim. So we don't have a claim on file for your provider with your uh total bill on this date of service.
[CUSTOMER][NEGATIVE] But we see a denial for this out of network.
[AGENT][NEUTRAL] OK, hold on one second.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And it's for [PII] or is it for one of his dependents?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] For the subscriber.
[CUSTOMER][NEUTRAL] A
[CUSTOMER][NEUTRAL] If you want, I can provide you the CPT code.
[AGENT][NEUTRAL] Is it, um, do you have claim number 3559882?
[CUSTOMER][NEUTRAL] No, it doesn't show here the EOB because we didn't receive the EOP yet.
[AGENT][NEUTRAL] The reason I'm asking is because there's only one claim on file for this data service. We, we only have one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, uh
[CUSTOMER][NEUTRAL] I can provide you the um CPT code. Is that OK for you?
[AGENT][NEUTRAL] Hold on 1 2nd.
[AGENT][NEUTRAL] I see what happened. Hold on one moment.
[AGENT][NEUTRAL] Let me see if this is it. Hold on one second, I'll see what happened.
[CUSTOMER][POSITIVE] Sure, take your time.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] You know
[CUSTOMER][NEUTRAL] Who
[AGENT][NEUTRAL] Alright, so we received the claim on [PII].
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim number is 35598. OK.
[CUSTOMER][NEUTRAL] Just a second. Yeah.
[CUSTOMER][NEUTRAL] 355. OK.
[AGENT][NEUTRAL] 9882.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And on [PII], the claim was denied because durable medical equipment is not covered on the policy.
[CUSTOMER][NEUTRAL] So, how it can be possible that it's uh not covered under policy?
[CUSTOMER][NEUTRAL] Because uh we received for the out of network and we are in network with American public life.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] So for one, so the primary insurance has its own benefits and secondary has its own benefits. If primary does not apply to the claim, secondary can't apply.
[AGENT][NEUTRAL] It was denied for primary, but for secondary.
[CUSTOMER][NEUTRAL] But you
[CUSTOMER][NEGATIVE] No, no.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] If you can check with the primary, the primary has already paid the amount.
[CUSTOMER][NEUTRAL] Etna.
[AGENT][NEUTRAL] OK, but for, for what I'm explaining to you is, if primary applied, secondary has its own coverage. Under their Medlink policy, durable medical equipment is not covered, which is why this claim is not.
[AGENT][NEGATIVE] is denied
[AGENT][NEUTRAL] So it doesn't matter that primary applied. Yes, we're second to them, but we have our own benefits and for our policy, durable medical equipment is not covered.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. Can you repeat your name, please?
[AGENT][NEUTRAL] Sure, my name is [PII] The first initials of my last name is.
[CUSTOMER][NEUTRAL] What about the color?
[AGENT][NEUTRAL] Go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] What was the call reference number?
[AGENT][NEUTRAL] There's no call reference number. You can use my name in today's date.
[CUSTOMER][NEUTRAL] That is [PII], right. And last initial is?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK. So, I have more claims, I mean, one more claim.
[AGENT][NEUTRAL] And is it for the same member or a different member?
[CUSTOMER][NEUTRAL] Different member.
[AGENT][NEUTRAL] OK, hold on one moment, let me note this policy.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] That is 0245.
[CUSTOMER][NEUTRAL] 2336 ML 8.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] That is [PII], and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that again for the call, the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] That is [PII].
[CUSTOMER][NEUTRAL] And the total charge would be $821.94.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] So this um policy was not active on the data service. Um, this policy termed on [PII], but there is an active policy, and that's policy number 2571016.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] So I'm gonna see if it's
[CUSTOMER][NEUTRAL] But as I can see here that uh we already received the payment.
[AGENT][NEUTRAL] I'm not saying that you did, and I'm just letting you know the policy number that you gave was no longer active. So I'm gonna look on the active policy and see what the claim status was.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And would this be the same provider on this claim?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And I received the claim on [PII].
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Claim number is 3557562.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim to the provider.
[AGENT][NEUTRAL] $742.60.
[CUSTOMER][NEUTRAL] So what about the 87038 uh CPT code? Why it's denied?
[AGENT][NEUTRAL] 80038.
[CUSTOMER][NEUTRAL] No, that is 87038.
[AGENT][NEUTRAL] 7038. OK. This that that code wasn't denied. It was paid $151.78.
[AGENT][NEUTRAL] You said 7038 or 7034?
[CUSTOMER][NEUTRAL] 7038.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEGATIVE] It says that this coat doesn't um meet the definition of durable medical equipment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] So let me see, this must be disposable. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] like
[AGENT][NEUTRAL] Yeah, for the filters, um, code 87038 is disposable. To be covered under the policy, it would need to be non-disposable.
[CUSTOMER][NEUTRAL] So are you saying that uh the policy is not uh not active for the data service or for the different?
[AGENT][NEUTRAL] I'm not saying that at all. I'm saying the filters that code A7038 is for.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] is disposable. The policy covers non-disposable. So that is why it's not, it's not covered because it's disposable. It's not about the coverage, it's the filters.
[CUSTOMER][POSITIVE] All right. Thank you so much.
[AGENT][POSITIVE] You're welcome. Was there anything else I could assist you with today?
[CUSTOMER][NEGATIVE] No thanks.
[AGENT][POSITIVE] Alright, well, thanks so much for calling APL. I hope you have a good day.