AccountId: 011433970860
ContactId: 466e72b7-a1e9-462b-99f4-4bb892c41a2c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1002479 ms
Total Talk Time (AGENT): 217498 ms
Total Talk Time (CUSTOMER): 522304 ms
Interruptions: 12
Overall Sentiment: AGENT=1.1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/466e72b7-a1e9-462b-99f4-4bb892c41a2c_20250225T15:02_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling for.
[CUSTOMER][NEUTRAL] Upstate Medical Associates PA please be informed that this call is being recorded and monitored for the quality and training purposes. I verified the EOB and this call is made for the additional information about the denial.
[AGENT][NEUTRAL] OK, I can help you with the claim. Can I please get your callback number just in case our call is disconnected?
[CUSTOMER][NEUTRAL] Yes, sure. It is [PII] and that's a direct line and I'm really sorry I missed your name. Could you please repeat that again?
[AGENT][NEUTRAL] Yes my name is [PII].
[CUSTOMER][NEUTRAL] Uh, may I know how do you spell that?
[AGENT][NEUTRAL] And [PII]
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] OK [PII], thank you so much for that.
[AGENT][NEUTRAL] May I also have the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Yes, uh, the name of the patient is [PII], and the date of birth will be [PII]. And uh
[CUSTOMER][NEUTRAL] And may I know what else? Policy number is the member ID number will be 02456436.
[AGENT][NEUTRAL] The policy number please?
[AGENT][NEUTRAL] OK, let me pull that up real quick.
[CUSTOMER][NEUTRAL] Yes, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and what is the um claim number for [PII]?
[CUSTOMER][NEUTRAL] Uh, let me check that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yes, the claim number will be?
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Just a moment, it's.
[AGENT][POSITIVE] Yes ma'am, go ahead, take your time.
[CUSTOMER][POSITIVE] Thank you. OK, thank you so much for that and I found.
[CUSTOMER][NEUTRAL] Uh, the claim number?
[CUSTOMER][POSITIVE] It is 355-933-8. That's the claim number and I'm really sorry.
[AGENT][POSITIVE] That's OK, that's fine. Let me look it up real quick so I can get your answers for you. You're welcome.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK I'm gonna put you on a brief hold while I look up this claim I'll be right back.
[CUSTOMER][POSITIVE] Yes, please. Take your time, no problem.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you so much for holding for me Sale. I have the claim pulled up for you.
[AGENT][NEUTRAL] The claim was paid. The claim was paid $2.72 with check num.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] And um sorry for cutting you off.
[CUSTOMER][NEUTRAL] And I'm sorry for cutting you off. Um, I apologize. We did not receive the payment for the procedure code 99214 and I'm checking only for the procedure code 99214. So, could you please check that?
[CUSTOMER][NEUTRAL] Please.
[AGENT][NEUTRAL] For procedure code 99214.
[CUSTOMER][NEUTRAL] Yes, we did not receive the payment and I'm checking only for that procedure cost. So could you please help me with the additional information about the denial I'm requesting you.
[AGENT][NEUTRAL] That is because office visits are not covered under the patient's policy.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK. So it's denied as it's not covered under the patient policy, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Thank you so much for that. Just, could you please give me a moment?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much for patiently staying connected, Tory, and I really appreciate your patience. Just to reconfirm it again, it was denied as it's not covered, uh not covered service as per the patient benefit plan, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Thank you so much for that.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And may I know under what criteria it is not covered?
[AGENT][NEUTRAL] Per the patient's policy.
[AGENT][NEUTRAL] It's a non-covered service.
[CUSTOMER][POSITIVE] OK. Thank you. OK. Thank you so much for that. OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] OK that's.
[CUSTOMER][POSITIVE] OK. Just a moment. I really appreciate your patience. May I know how are you doing today? OK. Yeah. Yeah, thank you so much for asking and I'm doing good as well and glad to hear that you're doing good.
[AGENT][POSITIVE] Thank you.
[AGENT][POSITIVE] I'm doing good.
[AGENT][NEUTRAL] How about you?
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] May I know the, OK, I don't have the time to filing limit, uh.
[CUSTOMER][NEUTRAL] It is 1, I'm sorry, it's 90 days from the date of service shall I take that?
[AGENT][NEGATIVE] And we do not have a timely filing limit.
[CUSTOMER][NEUTRAL] Oh OK, OK.
[CUSTOMER][NEUTRAL] Thank you so much for that. And just to reconfirm, it was already denied for the same denial reason. Uh, so may I know even after the appeal it is denied as, uh, for denied for the same reason, [PII].
[AGENT][NEUTRAL] Yes, it will be if you appeal it. Have you appealed it?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, let me check that. Yes, we recently submitted on [PII], so could you please check after that?
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Let me look.
[CUSTOMER][NEUTRAL] Please, yeah, just to reconfirm, is this the latest denial, that's it.
[CUSTOMER][NEUTRAL] What is that?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Alright
[AGENT][NEUTRAL] We did receive um an.
[AGENT][NEUTRAL] A claim on.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] That was processed on [PII] from your facility.
[AGENT][NEUTRAL] And it was denied because benefits are payable only if your major medical insurance provider provides benefits. If this claim is later paid by your major medical insurance, please send the explanation of benefits showing benefits were paid.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, so what is the latest then I'll now uh exactly? Could you please repeat it?
[AGENT][NEUTRAL] Benefits are payable only if your major medical insurance provider provides benefits.
[CUSTOMER][NEUTRAL] So after the update?
[AGENT][NEUTRAL] If this claim.
[AGENT][NEUTRAL] If this claim is later paid by your major medical insurance, please send the explanation of benefits showing benefits were paid.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I don't.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. Thank you so much. Uh, just a moment. So the denial is after, after the appeal, it was denied as the benefits are payable only if the major medical insurance provides the benefits, right? Thank you so much. Just a moment.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] And that was um.
[AGENT][NEUTRAL] That was.
[AGENT][NEUTRAL] The claim
[AGENT][NEUTRAL] And I can give you the procedure codes.
[CUSTOMER][NEUTRAL] Uh, no, I'm checking only for the procedure code 99214, and that code was denied as benefit plan, uh, benefit after the appeal, it was denied that the, uh, provider must submit the no.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] 99214.
[AGENT][NEUTRAL] Is the office visit and office visits are not covered under the patient's policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. I'm checking only for that procedure code, sorry. So, uh, OK.
[AGENT][NEUTRAL] Oh OK, yeah, so office visits are not covered.
[CUSTOMER][NEUTRAL] OK. So even after the appeal, I just do, uh, thank you so much for that. Just want to uh confirm that. Uh, we have sent an appeal, even after the appeal, it was denied for the same reason that is not covered as for non-covered service as for the patients benefit plan. Is that right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Thank you so much for that. And could you please go ahead and help me with the
[CUSTOMER][NEUTRAL] Yeah, there is no time to filing limit, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. And I do have the mailing address. Could you please verify with that?
[AGENT][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] That's [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Zip code is [PII], right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you so much for that.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, just a moment, so you received the bill, right?
[CUSTOMER][NEUTRAL] Which was sent on [PII].
[AGENT][NEUTRAL] I did not see anything sent on [PII].
[CUSTOMER][NEUTRAL] OK, we recently submitted the bill on, um, OK.
[CUSTOMER][NEUTRAL] Just a moment. OK, we recently submitted on [PII]. That's when you received, right?
[AGENT][NEGATIVE] No, I don't see anything received on [PII].
[CUSTOMER][NEUTRAL] May I know when did you receive that?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I never.
[AGENT][NEUTRAL] I read you the one that we received on [PII] that said that.
[AGENT][NEUTRAL] We need the EOB showing the primary insurance paid their part and we can't process the claim unless the primary paid.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. So, thank you so much for that. Uh, the denial, OK. Let me reconfirm all the information. Uh, the 99214, the procedure code was, uh, received, was denied for the reason that is is it's not covered as not covered service as per the patient policy. Is that right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, so that's, uh, you received it on [PII]. That is the denial reason for the procedure code 99214. Is that right, [PII]?
[AGENT][NEUTRAL] No, we did not receive it on that date, we received it on.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Um yes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We received it on.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] [PII] and processed it on [PII].
[CUSTOMER][POSITIVE] Thank you. OK, perfect. Thank you so much for that.
[AGENT][NEUTRAL] And we, and we paid.
[AGENT][NEUTRAL] And we paid $2.72 with check number 2026033.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] You mean for the procedure code 99214?
[AGENT][NEUTRAL] That check one out
[AGENT][NEUTRAL] No, we did not pay for that procedure code because office visits are not covered under the patient's policy.
[CUSTOMER][NEUTRAL] No, I'm checking.
[CUSTOMER][NEUTRAL] OK, I'm, I'm requesting you. I'm checking only for the procedure code 99214 that is denied. It's not covered as per the patient benefits plan. Is that right, sorry?
[AGENT][POSITIVE] Yes, I believe we've established that.
[CUSTOMER][NEUTRAL] Yeah, thank you so much for that. And OK. Could you please go ahead, uh, that is the reason denial, right, for the procedure code.
[AGENT][NEUTRAL] Again, yes.
[CUSTOMER][NEUTRAL] Yeah, could you please go ahead and provide the call reference number?
[AGENT][NEUTRAL] Yes, you can use my name it's [PII] and today's date.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] OK, thank you so much for your assistance and patience as well. Have a great day. Take care. Bye for now.
[AGENT][POSITIVE] You too [PII]. bye bye. You have a good day and thanks for calling APL.