AccountId: 011433970860
ContactId: 3efe8b08-74e3-4c1a-a393-653b0c506e22
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 556570 ms
Total Talk Time (AGENT): 177601 ms
Total Talk Time (CUSTOMER): 198955 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/20/3efe8b08-74e3-4c1a-a393-653b0c506e22_20250620T17:35_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] calling from provider's office. I'm checking on uh uh denal claim.
[AGENT][NEUTRAL] OK, well, I'll be more than happy to assist you with the claim [PII]. And [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Yes, the callback number [PII].
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] The member ID that could be mm.
[AGENT][NEUTRAL] You've received the claim denial already?
[CUSTOMER][NEUTRAL] Sure one moment.
[CUSTOMER][NEUTRAL] Yes, uh, the member ID is, OK, one moment, I will.
[AGENT][NEUTRAL] What's the claim number?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Whichever one you have is fine.
[CUSTOMER][NEUTRAL] Yes, OK.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] The claim number is 3604346.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And can you verify the member's um first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes, the patient name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And let me see.
[AGENT][NEUTRAL] Hold on one moment
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Sort code [PII] was denied because office visits are not covered on this policy.
[CUSTOMER][NEUTRAL] Uh, office visit is not covered, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. Uh, but you pay the remaining two courses, right?
[AGENT][NEUTRAL] We paid out on 11102 and 11,300.
[CUSTOMER][POSITIVE] Yes, you paid that one.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh, but you denied 99213.
[AGENT][NEUTRAL] Yes, and 88312.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yes, may I know the reason for that?
[AGENT][NEGATIVE] Um, for 88312, it was denied.
[AGENT][NEUTRAL] Because benefits are payable only.
[CUSTOMER][NEUTRAL] No, I'm asking.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] I'm asking about 99213.
[AGENT][NEGATIVE] Oh, OK, as I advised, it was denied because office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] Uh, but here all our uh office visit only, right? That 11102 and 1130, that two office visit, but you paid that two quotes, you denied that 99213.
[CUSTOMER][NEUTRAL] Would you please take this claim back for review?
[AGENT][NEUTRAL] Hold on one moment. Hold on one moment.
[CUSTOMER][NEUTRAL] OK. Mhm.
[AGENT][NEUTRAL] Not 11102 is not a place of service code, that's a treatment code for a biopsy.
[AGENT][NEUTRAL] And code 11.
[AGENT][NEGATIVE] 300 is also not a place of service code that's the the procedure that was done, the skin shaving. So those are not office visit codes, which is why they were paid out on versus the 99213, which is a place of service code.
[CUSTOMER][NEUTRAL] So office visit is not covered, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] As per patient's plan or provider's plan?
[AGENT][NEUTRAL] As per patient's plan.
[CUSTOMER][NEUTRAL] So is that a patient responsibility?
[AGENT][NEUTRAL] We don't determine patient responsibility because we're not the major medical insurance company.
[CUSTOMER][NEUTRAL] OK, you said it's uh not covered under uh as per patient's plan, whether the the uh amount is uh under patient's responsibility or it's a provider write off.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Right, and the answer to that question is we don't determine patient responsibility because we're not the major medical. So it would be up to you as the provider and or primary insurance to determine if it's a write-off, if it's billed to the patient, that's not up to us as a secondary insurance.
[CUSTOMER][NEUTRAL] So it's up to our right to it's a provider right for top for patients responsibility based on primary insurance.
[AGENT][NEUTRAL] Right, because we're the secondary insurance, correct.
[CUSTOMER][NEUTRAL] Right?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Mhm, sure.
[CUSTOMER][NEUTRAL] OK. Shall I move on to the uh next member ID? Could you, uh, before that, could you please give me the call reference number for this claim?
[AGENT][NEUTRAL] So the call reference number for the entire call will be my name and today's date.
[AGENT][NEUTRAL] And that's [PII].
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Yes, uh, I, I do have uh one more claim.
[AGENT][NEUTRAL] So a total of 2 or 3?
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Yes, 2.
[AGENT][NEUTRAL] OK, and then hold on one moment, let me finish these notes and we can move on to the next one, OK?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, hold on one second.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and the next member's policy number whenever you're ready.
[CUSTOMER][NEUTRAL] you
[CUSTOMER][NEUTRAL] Yes, sir, I have a claim number that is 383606765.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 3606765
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh, my name is uh [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment, let me locate the claim for you.
[AGENT][NEUTRAL] OK, so all the calls were paid out on except for [PII], which was denied because office visits are not covered on the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] As per patient's policy, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] Office visit code is not covered.
[CUSTOMER][NEUTRAL] Uh
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Is that a patient responsibility or provider write off?
[AGENT][NEUTRAL] Uh, we don't determine patient responsibility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] OK, that's all the claim I have. Thank you for your assistance. Have a nice day and happy weekend.
[AGENT][POSITIVE] Thank you, [PII]. You also, I hope you have a great weekend as well and thanks for calling ATL. Bye-bye.
[CUSTOMER][POSITIVE] Yeah, thank you. Bye.
[CUSTOMER][NEUTRAL] OK.