AccountId: 011433970860
ContactId: 462124dc-51b8-4b26-82fe-5a9bb9bde13a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1028540 ms
Total Talk Time (AGENT): 481735 ms
Total Talk Time (CUSTOMER): 473813 ms
Interruptions: 7
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/02/462124dc-51b8-4b26-82fe-5a9bb9bde13a_20250502T19:52_UTC.wav
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[CUSTOMER][NEUTRAL] Oh.
[AGENT][POSITIVE] Thank you hello.
[CUSTOMER][NEUTRAL] Hello hey.
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII].
[CUSTOMER][NEUTRAL] Who's that? Hey, [PII], it's [PII]. How are you doing?
[AGENT][POSITIVE] Doing well, [PII], thank you. How are you?
[CUSTOMER][NEUTRAL] If I can teleport uh, uh, a karate chop to the throat, I would. But anyway, I'm gonna be good.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, I have a provider on the call. He is calling about a claim status for Metlink plan.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] We call for 2 days of service. The first day of service, we processed as needing the primary EOB twice and then uh the second time, well, 1 and 2nd time process is needing the correct EOB and I explained to him on the ELB the amount on the EOB does not match what's on the claim.
[CUSTOMER][NEGATIVE] And he's telling me, well, you've already processed one for [PII] of the same date and it has the same information which I don't understand why whatever it it wasn't processes, uh, needing correct L be it was just processed and paid.
[AGENT][NEUTRAL] Oh boy, OK.
[CUSTOMER][NEUTRAL] And he wants to know why we paid on one but not on the other and I, he saw you paid. I said, no, sir, I did not.
[CUSTOMER][NEGATIVE] But he, he, uh, uh, he kept interrupting me the whole time. Like I couldn't even, I'm just warning you, when I told him I was like, well, the claim process is needing uh the correct EOB. He said, you received it. And when I tried to tell him, he said, well, I'm not talking about the, the last time, I'm talking about the second time. I was like, wait, what? But anyway.
[AGENT][NEGATIVE] Oh jeez. OK.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Uh, yes, ma'am.
[CUSTOMER][NEUTRAL] So it's like, dude.
[CUSTOMER][NEUTRAL] Anyway, but um.
[AGENT][POSITIVE] OK, sounds like a fun call.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] It is, and I appreciate you. Uh, policy number is 1986343.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, the first day of service he called about it was [PII] or [PII].
[CUSTOMER][NEUTRAL] In the amount of 264. 57.
[CUSTOMER][NEUTRAL] And the next one was [PII], and at the same amount.
[AGENT][NEUTRAL] 26457.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and it's for [PII], is that right?
[CUSTOMER][NEUTRAL] And I get
[CUSTOMER][NEUTRAL] Uh yes. Yes, ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Patients been verified correct?
[CUSTOMER][NEUTRAL] Yes, I verified all the information verify him or.
[CUSTOMER][NEUTRAL] Um, got his callback number, you know he said extension really fast, but yes, I verified information.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What's his name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII] and what's the callback number [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Alrighty I will do my best to.
[AGENT][NEUTRAL] Assistant.
[CUSTOMER][POSITIVE] You rock, of course, I appreciate you.
[AGENT][POSITIVE] No problem and you can go ahead and send him through when you're ready thank you hope you have a great weekend.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] All right lady have a great weekend, you too.
[AGENT][POSITIVE] You too thanks bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hi, my name is [PII]. I'm in the claim support team and [PII] transferred you over to me to further assist you. Uh, you needing some information on a claim status for Ms. [PII], is that right?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][POSITIVE] Yes, yes, right.
[AGENT][NEUTRAL] OK. And the day, um.
[CUSTOMER][NEUTRAL] And by the by the how are you?
[AGENT][POSITIVE] I'm doing well thank you how are you?
[CUSTOMER][POSITIVE] Yeah, I'm doing well thank you for asking.
[AGENT][NEUTRAL] OK, so it looks like we're working with 22 data service, is that right?
[CUSTOMER][NEUTRAL] Yes, and the main concern of the date of service is [PII].
[AGENT][NEUTRAL] [PII], right? OK.
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So just give me a moment I'm gonna pull up these documents and just.
[AGENT][NEUTRAL] Take a look and see what we're working with here.
[CUSTOMER][NEUTRAL] Yes, please take a look.
[AGENT][NEUTRAL] So we did receive the claim.
[AGENT][NEUTRAL] And we needed the explanation of benefits from the primary insured insurance.
[AGENT][NEUTRAL] For this data service.
[CUSTOMER][NEUTRAL] OK, but yeah.
[CUSTOMER][NEUTRAL] OK, but you have already received the primary OB, but as for you, you said the primary is incorrect, so I just gave you the reference, uh, the date of service [PII]. You receive the same, uh, primary OB with same, uh, CPT code and the bill amount and you, um, process the claim on the behalf of primary OB.
[CUSTOMER][NEUTRAL] And uh uh for this state of service which is [PII], you, you are not processing this claim while the information of primary will be same CPT code and uh build amount is same so I just want to know the reason you have one of one of the date of service you process with the same information and other hand you will, you are not processing the claim with the same information. Why, uh, why it's happening.
[AGENT][NEUTRAL] Yeah, let me just take a look at that. So you're saying that we had a claim for [PII] data service for the same uh information, right?
[CUSTOMER][NEUTRAL] Uh, it's the date of [PII]. Yes, the primary of of the CPT code is 9083 code and uh the total charge amount is $198.92. So on the behalf of primary will be, you have already, uh, processed and paid the $50 amount for the date of service [PII].
[CUSTOMER][NEUTRAL] And uh our date of service is [PII], and we, uh, we send the primary OB with the same CPT code because BCBS do not pay any other CPT code apart from S9083 code. So how can I provide the ENM code and the same charges because if the CPT code will be changes, the charge amount automatically will change.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So I cannot provide you the same CPT code and charge amount which processed by the primary.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so just um give me one minute. OK, so what happened here is that we did receive that CMS form and the CPT code of 99213 for the charge amount of 264. 57, OK? So then when we uh received the uh when we we denied that for the EOB from the primary insurance and then what we received subsequently was on 48.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] that
[AGENT][NEUTRAL] Um, I'm, I'm sorry, we received it on 44, my apologies. So what happened is that um there was some.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] Office notes attached in addition to the office notes, the explanation of benefits it looks like from Blue Cross Blue Shield of Oklahoma.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] So the charges didn't match and the CPT code is different, so our adjuster that processed the claim called your office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And spoke to [PII].
[AGENT][NEUTRAL] Do you know who that is?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so she called and spoke to [PII] on [PII] and she let them know that um.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The bill to the major medical with the the CPT code of S9083 was for global payments, but she was gonna check with the supervisor to figure out how they can get the CMS form to match what was shown on the EOB from Blue Cross Blue Shield.
[AGENT][NEUTRAL] Because what's happened here is while it does show that copay amount it's a different build amount and a different CPT code, so in order for this plan to pay that information needs to match it needs to match what was billed to us on that CMS form because it's a completely different amount and a different CPT code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So if we, uh, if we are talking about the uh date of [PII], so it is also completely uh like completely different, uh, and uh this is not match, uh, match the primary will be with the claim form American public life insurance as well.
[AGENT][NEUTRAL] For what date? I'm sorry?
[CUSTOMER][NEUTRAL] So why the date of [PII]. So why this claim, uh, got processed?
[CUSTOMER][NEUTRAL] This claim should not process. If this claim was already processed, then on the behalf on the reference, the date of service [PII], this claim also should be processed.
[AGENT][NEUTRAL] OK, let me take a look at that. Bear with me for just a moment while I pull that claim, OK?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yes, and I just want to tell you, please take a look for date of service [PII]. You will receive the primary you will be with different CPT and charge amount, but still you process the claim.
[CUSTOMER][NEUTRAL] And that uh the claim in the claim form, the CPT code and charge amount bill amount is also different. Still you will you process this claim.
[CUSTOMER][NEUTRAL] And paid.
[CUSTOMER][NEGATIVE] So why was happen for this date of service and why is this.
[AGENT][NEUTRAL] Well, I can, what, what happened with that, um, [PII], what happened with that claim for the the data service you're speaking of, um, on the [PII].
[AGENT][NEGATIVE] That claim was processed in error because we don't ever the the claim was processed in error because the CPT code and the charges do not match what's on the CMS form. Now why that was processed that way I can't speak to that but what I can tell you is that the charges and the CPT code don't match. So even if the charges possibly because this is um urgent care service.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] So even if the CPT code didn't match, at least if the charges matched, that could be the reason. Now why the claim for [PII] was processed, I can't speak to that. I didn't process the claim, but I can tell you that it should not have been processed, so it was processed in error because the CPT.
[CUSTOMER][NEUTRAL] All
[CUSTOMER][NEUTRAL] You.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] and charges do not match and for this policy it has to it's very specific that those charges are this policy is like a supplemental gap policy and what this policy does is it covers co-insurance and deductible amounts for services that is covered under the plan.
[CUSTOMER][NEUTRAL] Hey
[AGENT][NEUTRAL] But those services have to point to, like I said, they have to meet that criteria and have that co-insurance and or deductible amount, but those charges and CPT codes should match or at least be the same charge amount. It's not, it's not the same charge amount. So on the CMS form it shows 26457, but on the um on the explanation of benefits that was sent to [PII] it was sent as 19892 is the bill charge.
[CUSTOMER][NEUTRAL] Yes, this is why because as per the contract of BCBS they pay only S9083 code. They do not pay ENM code or anything CPT code, anything else apart from S9083 code. They do not pay any CPT code. So how they will process, um, another code.
[AGENT][NEUTRAL] Um, that I'm not sure. I, you're saying that they don't accept any other code but the S code?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Oh, no problem, thank you so much. Please provide me call reference.
[AGENT][NEUTRAL] Um, so do you know if [PII] was able to get with the supervisor to figure this out?
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] You.
[AGENT][NEUTRAL] So that we can have the matching, we can have the matching amount on the uh major medical explanation of benefits.
[CUSTOMER][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] But we cannot provide you the um um matching uh code and build amount because BCBS pay with different CPT and build amount so I can how I can.
[CUSTOMER][NEUTRAL] Uh, how can I provide you the same, uh, charge amount and bill amount and CPT code as well.
[AGENT][NEUTRAL] Well that's what we're trying to figure out like I said, we, we did call and and reach out and try to to verify the information and then like I said we were told that Callie was gonna get with the supervisor um on on how we can match the billing with the explanation of benefits so.
[CUSTOMER][NEGATIVE] So it is not possible, uh.
[AGENT][NEUTRAL] Can't your billing department make the CMS form match what the EOB says? That's what we're trying to accomplish here.
[AGENT][NEUTRAL] Do you understand?
[CUSTOMER][NEUTRAL] Uh, yes, I understand. um, OK, no problem, please provide me your mailing address, um.
[AGENT][NEUTRAL] Certainly, so you can um mark it you wanna mark it as an appeal and then you're gonna wanna um pro provide us uh supporting documents as to why this information is um is not matching so you'll wanna mark it as an appeal, send supporting documents and it will come to us at APL.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And it's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh, OK, so you said [PII], right?
[AGENT][POSITIVE] Right, and like I said, you'll make sure you mark it as an appeal.
[AGENT][NEUTRAL] And then and provide us some supporting documents as to why there's a conflict um and why the charges don't match what's uh why the charge in the CPT code doesn't match what's on the CMS form from the primary insurance EOB.
[CUSTOMER][NEUTRAL] OK. And what?
[CUSTOMER][NEUTRAL] OK, OK, I, I got it and what I can put as an attention?
[AGENT][NEUTRAL] The reference
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] No, what I can put as attention like a department or.
[AGENT][NEUTRAL] Oh attention is appeals, uh huh, appeals department, yes I'm sorry.
[CUSTOMER][NEUTRAL] OK. And what is the bill timing limit?
[AGENT][NEUTRAL] Um, the appeal limit is, it's, uh, 180 days from the denial date.
[AGENT][NEUTRAL] Which that would be the uh 47 or 48.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 48 was the last uh the last uh claim number for this service and that you wanna reference the claim number? Do you have it?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Uh, no problem, I have.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] And did you have any other questions, [PII]?
[CUSTOMER][NEUTRAL] Uh, no, please provide me call reference.
[AGENT][NEUTRAL] Certainly it's my name and today's date, first name [PII]
[AGENT][POSITIVE] And the last initial [PII] and again today's day.
[CUSTOMER][POSITIVE] OK, thank you so much, [PII], for assisting me. Have a good day. Bye for now.
[AGENT][POSITIVE] You too, [PII], thank you so much for calling APL have a great day and a great weekend.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.