AccountId: 011433970860
ContactId: 54ce77dc-fa08-422a-a449-0bbf4159ca0f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1942050 ms
Total Talk Time (AGENT): 629944 ms
Total Talk Time (CUSTOMER): 509254 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/03/54ce77dc-fa08-422a-a449-0bbf4159ca0f_20250603T18:00_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, this is [PII] calling from Skin and Cancer Associates. How are you doing today?
[AGENT][POSITIVE] I'm doing well, solo. How are you?
[CUSTOMER][POSITIVE] I'm also doing good, thank you for asking. And I'm calling to check the claim status.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Uh, I have 10 to 15 claims to check the status.
[AGENT][NEUTRAL] OK, I can assist you with the 1st 5 and the others can be done on the online service center. May I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes. Uh, before I proceed with that, may I know your good name, please?
[AGENT][NEUTRAL] Yes, my name is [PII].
[CUSTOMER][NEUTRAL] It is [PII]?
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][POSITIVE] Thank you, [PII]. Thank you for that. And my good callback number is [PII] and it is a direct line.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Alright, and may I have the first member's policy number?
[CUSTOMER][NEUTRAL] Yeah, before I go with the member ID, uh, please be informed that this call has been recorded for quality and training purpose. Would you like us to continue the recording?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, that's fine.
[CUSTOMER][POSITIVE] Uh, thank you, [PII]. Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yeah. And the patient's ID is [PII].
[AGENT][NEUTRAL] Alright, and can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Patient's first name is [PII] and the last 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 I am, um, well, may I have the date of service and the total bill for the claim?
[CUSTOMER][NEUTRAL] Date of service is [PII] and the total bill amount is $468 even.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold, and 468 is the only total that it could be?
[CUSTOMER][NEGATIVE] Sorry, I did not get you.
[AGENT][NEUTRAL] Is $468 the only total that the claim can have?
[AGENT][NEUTRAL] Or, OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the on the claim?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Would that be the same as the beginning of the call, the skin and cancer associates?
[CUSTOMER][POSITIVE] Yes, that is right.
[AGENT][NEUTRAL] Alright, so I'm showing that we received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 358.
[AGENT][NEUTRAL] 5040.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim to the provider. Uh, let me get that total for you. A total of $49.98.
[AGENT][NEUTRAL] And did you need the check information or anything?
[CUSTOMER][NEUTRAL] Yes, uh, we, uh, I see that we
[CUSTOMER][NEGATIVE] We received only payment for the one CPT that is for 11102, and there is no response for the another CPT that is of 99203. May I know what is the status of this 91?
[AGENT][NEGATIVE] Yes, 99203 was denied because office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] Office visits are not covered by this policy.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Uh, that is only for this particular patient or for the, this plan med meddling group med supplement. For all these plans, is the office visits are not covered?
[AGENT][NEUTRAL] It's just, it goes per policy, so if this patient's policy does not have office visit coverage.
[CUSTOMER][NEUTRAL] Oh, OK. I have, because we see most of the claims, we are not getting payments for the ENM code, that is for office visits.
[AGENT][NEUTRAL] Right, it's it's, it, it's, it's better to go by person by person because each policy can have something different, but for this particular patient, she there's no office um coverage on the policy. There could be another Metlink policy that does have coverage, but this patient does not.
[CUSTOMER][POSITIVE] Yes, thank you, [PII]. Thank you for your information. And can I get the call reference for this number?
[AGENT][NEUTRAL] Welcome.
[AGENT][NEUTRAL] Yes, so the call reference number for the entire call is going to be my name and today's date, and the first initial to my last name is [PII].
[CUSTOMER][POSITIVE] OK. Thank you, [PII], thank you for that.
[CUSTOMER][NEUTRAL] And can I go with the another member?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Um, hold on one moment, I'm noting um this claim or this policy.
[CUSTOMER][POSITIVE] Yes, yes, please.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] I'm there, I'm there, hello? Yes.
[AGENT][POSITIVE] All right, thank you so much for holding. And may I have the next member's policy number?
[CUSTOMER][NEUTRAL] Yes, it is 01894936. M as in Mike, L as in Lima, and number 8.
[AGENT][NEUTRAL] Alrighty, can you verify the member's first and last name and date of birth?
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yes, the member's first name is [PII] and the last name is [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that. And again, all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bill for the claim?
[CUSTOMER][NEUTRAL] Yes. It is [PII] and the total bill amount is
[CUSTOMER][NEUTRAL] $747 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And that was [PII]?
[CUSTOMER][POSITIVE] Yes, that is right.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] There's another policy, so this policy, um,
[AGENT][NEUTRAL] Ending in 4936, terminated on [PII].
[AGENT][NEUTRAL] But there's an active policy number 256.
[AGENT][NEUTRAL] 9076.
[AGENT][NEUTRAL] This policy has been active since [PII].
[AGENT][NEUTRAL] So I'm gonna look and see if there's a policy here under the active, if there's a claim under the active policy because the policy number you provided is terminated.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] And you said the total bill is $747?
[CUSTOMER][POSITIVE] Yes, that is right.
[AGENT][NEUTRAL] OK, let me see
[AGENT][NEUTRAL] Alright, so I'm showing we received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 358.
[AGENT][NEUTRAL] 3251.
[AGENT][NEUTRAL] And on [PII], the claim, uh, we paid out on the claim, a total of $4.85.
[AGENT][NEUTRAL] 217004.
[AGENT][NEUTRAL] Procedure code 99213 was denied because office visits are not covered on the policy.
[CUSTOMER][NEUTRAL] Office visits are not covered under the policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, so, may I know only uh $4.85 are paid for the another CPT. May I know what is the allowed amount for the other CP the CBT?
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] So the max, I mean, the allowed amount is up to $4000 per calendar year, but the reason this was paid the $4 and hold on, I'm trying to go back to the change, $4.85 is because that's what that code was, that's what was billed to us for that code.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Oh, that is the only allowed amount for the CPT, the $4.85.
[AGENT][NEUTRAL] The allowed amount is $4000. We paid $4.85 because that's what the bill said was due for that code for 17004, the charge on the on the paperwork that you sent over was $4.85 so we paid $4.85.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So, as this office visits are not uh covered under the patient's plan, so can we build this, uh, can we build these charges from the patient?
[AGENT][NEUTRAL] Um, so we don't determine patient responsibility. Uh, the remaining balance would be up to your discretion as the provider.
[CUSTOMER][NEUTRAL] That means it would be under the provider's discount?
[AGENT][NEUTRAL] We do not determine patient responsibility.
[AGENT][NEUTRAL] So for the remaining balance, that will be at you as the provider's discretion to how you want to handle it. We can't advise on that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Uh, thank you, [PII]. Thank you for your information. Yes.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] So, can I move to the another member?
[AGENT][NEUTRAL] Um, yes, hold on one moment, I'm just noting this policy.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] Just one line up you have to write. This has been done. Got it. Only 2 or 3 you must have received not much and very simple and that is a production as one scenario might be we have a.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] The next member's policy number is 02481553.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, the member's first name is [PII]. The last 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.
[AGENT][NEUTRAL] And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] Yes, it is [PII] and the total bill amount is $348 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Alright, so I'm showing we received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 357.
[AGENT][NEUTRAL] 9302.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim to the provider a total of $55.81.
[AGENT][NEUTRAL] For code 17,000.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Code 99213 was denied because office visits are not covered on the policy.
[CUSTOMER][POSITIVE] Yes. Well, thank you, and I thank you for that. Uh.
[CUSTOMER][NEUTRAL] So for these members, uh, in which the plan, which the plan, the office visits are not covered, is there any plan name on the ID cards?
[AGENT][NEUTRAL] Are you, wait, say that again. So you wanted to know what the plan name shows on the ID cards?
[CUSTOMER][NEUTRAL] Uh, we see that it is meddling group met supplement plan.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[AGENT][NEGATIVE] I don't understand the question.
[CUSTOMER][NEUTRAL] Um, so
[CUSTOMER][NEUTRAL] So, has the uh office visits are not covered under this patient's plans. So we can see any specific plan name on the member ID cards.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] No, not outside of what you read, um, that's all tha[PII]'s listed on the card.
[CUSTOMER][NEUTRAL] OK, because if there is any specific plan name, uh, in the, in which these office visits are not good, that could be easy to find out as for this plan, this office visits are not covered. That, that is the reason I'm asking for that.
[AGENT][NEUTRAL] Right, I understand. It's just easier to go by per person because even if they have the same type of policy, they can still add or or change things. So it could be the same type of policy product, but they can, you know, take things off or add things, so it will still be different.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yes, OK. [PII], thank you for your information.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yeah. Uh, so, can I go for the another member?
[AGENT][NEUTRAL] Um, hold on one moment, I'm almost finished with this one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, the next member's policy number?
[CUSTOMER][NEUTRAL] Yes. Yeah, the, the next member's policy number is 02556090.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, uh,
[CUSTOMER][NEUTRAL] Member's first name is [PII] and the last name is [PII]. And the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] Yes, the date of service is [PII] and the total bill amount is $504 even.
[AGENT][NEUTRAL] OK, hold on one moment, 504.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] I believe I just located the claim. I'm waiting for it to come up now. Hold on one moment.
[CUSTOMER][POSITIVE] Yes, sir. Not a problem. Please take your time.
[AGENT][NEUTRAL] So I'm showing the claim was received on [PII].
[AGENT][NEUTRAL] The claim number is 357.
[AGENT][NEUTRAL] 8966.
[AGENT][NEUTRAL] And on [PII], the um we paid out on the claim.
[AGENT][NEUTRAL] A total of $85.17.
[AGENT][NEUTRAL] Zip code [PII].
[AGENT][NEUTRAL] 99214 was denied because office visits are not covered by this policy.
[CUSTOMER][POSITIVE] Thank you, [PII]. Thank you for your information.
[AGENT][NEUTRAL] You're very welcome. Hold on one moment while I note this one.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] Yes, the next member's policy number is 1130586.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] And the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, my first name is [PII], and the last name is [PII]. And the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service and the total bill for the claim?
[CUSTOMER][NEUTRAL] Yes, the date of service is [PII] and the total bill amount is $787 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And it's $787.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Do you mind if I place you on just a brief hold?
[CUSTOMER][POSITIVE] Yes, please take your time.
[AGENT][NEUTRAL] OK, thank you. Hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] That's the same
[AGENT][NEUTRAL] 7:35.
[AGENT][NEUTRAL] Hello Solo.
[CUSTOMER][NEUTRAL] Yes, hello.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. So we do have a claim here on file for this data service and it is from your provider, but it's a different bill amount.
[CUSTOMER][NEUTRAL] A different bill amount?
[AGENT][NEUTRAL] Yes, and it's the only claim for that day. Do, do you want to see if this is it?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so the claim, uh, the total that I'm showing for the claim is $560.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you show that figure anywhere on your end?
[CUSTOMER][NEUTRAL] I'm checking for that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Yes, as per the checking, uh, the total bill amount is 787. So that is of 3 CPTs. For the, for APL we have bill only two CPTs that is 99214 and 10,060. So that is the difference uh for the bill amount which I have shared you. For the both CPTs that you mentioned bill amount is correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so are you needing the claim status or you, you need to submit the claim for the other code?
[CUSTOMER][NEUTRAL] Please wait for a moment. I'm checking for that.
[AGENT][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] Uh, thank you, [PII]. Thank you for being on hold. Uh, so can I get the status for this claim? Uh so, uh, for the another CPT we have received all the payments from the primary insurance.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So that is the reason we have built only 2 CPTs for this.
[AGENT][NEUTRAL] OK, so it's the total bill is $560. OK. So we received this claim on [PII].
[AGENT][NEUTRAL] The claim number is 358.
[AGENT][NEUTRAL] 2735.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim a total of $25.
[AGENT][NEUTRAL] Zip code [PII].
[CUSTOMER][NEUTRAL] Uh, this was paid to [PII]?
[AGENT][NEUTRAL] Yes, this was paid to [PII]. This policy has a physician benefit rider, so it's different than the others.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, may I, may I know the reason for the CPT 10,060 why it was not paid?
[AGENT][NEUTRAL] Yes, it wasn't paid because the per office visit is per day and this is all the same day of [PII], so it was applied to the first code.
[CUSTOMER][NEUTRAL] Sorry, I did not get that. Can you repeat it once again?
[AGENT][NEUTRAL] Both codes use the same benefit.
[AGENT][NEUTRAL] So we can only apply it once because it's the same date of service. So we applied it to the first code that was filed, which is the 99214.
[CUSTOMER][NEUTRAL] Uh, but as for the DX codes, there are the different DX, no, for the, both the CPTs then how it can be same for the boots.
[AGENT][NEUTRAL] It's the same benefit that's being used, not the same codes, the same benefit, the physician office fee?
[AGENT][POSITIVE] So that benefit
[AGENT][NEUTRAL] OK, I don't know how, there's only one, hold on.
[CUSTOMER][NEUTRAL] Oh, the CPT 100?
[AGENT][NEUTRAL] There's only one, you can only apply a benefit one time. The benefit is a physician's office fee, office fee um benefit that helps pay towards the physician's office. So because, yes, there are two separate codes, but they, the data service is [PII], so it's the same day. So you can only apply one benefit for one day. So we applied it to the 99214.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. So, as you mentioned that for the one day of service, there will be only one benefits cover, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK. Uh, so the, then, then what about the another CPT, uh, that can be billed for charges from the, uh, patient?
[AGENT][NEGATIVE] I don't understand the question.
[CUSTOMER][NEUTRAL] So, as you mentioned that you, you will be paying only for the one benefit, so one CPT. So the another remaining CPT can be charged.
[AGENT][NEUTRAL] Not for CPT.
[AGENT][NEUTRAL] Not per CPT per data service.
[CUSTOMER][NEUTRAL] Yeah, benefits, right?
[CUSTOMER][NEUTRAL] Yes, for date of service, there will be only one benefits covered. So, for the another benefits, we can bill it to the patient.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, we don't determine patient responsibility. So for the remaining balance that would be up to whatever your policies or procedures are.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yes. Thank you, [PII]. Thank you for your information.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And hold on one moment, I'm just noting this one and then we can move to the last one. Hold on one second.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] Yes, the next members.
[CUSTOMER][NEUTRAL] Yes, the next member's policy number is 01960608 and M as in Mike, L as in Lima, number 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] Yes, the member's first name is?
[CUSTOMER][NEUTRAL] And numbers first name is [PII] and the last name is [PII].
[CUSTOMER][NEUTRAL] 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. May I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] The date of service is [PII] and the bill amount is $536 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Alright, so I'm showing this claim was received on [PII].
[AGENT][NEUTRAL] The claim number is 338.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] 356 6.
[AGENT][NEUTRAL] And on [PII], the claim, um, we paid out on the claim.
[AGENT][NEUTRAL] A total of $80.52.
[AGENT][NEUTRAL] For code 17,110.
[AGENT][NEUTRAL] Code 99214 was denied because office visits are not covered on this policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Mm thank you, [PII]. Thank you for your information.
[AGENT][POSITIVE] You're very welcome. Was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] No.
[AGENT][POSITIVE] Alrighty, well, thank you so much for calling APL Solo. I hope you have a good day.
[CUSTOMER][POSITIVE] Thank you and bye for now. Have a nice day.
[AGENT][POSITIVE] You're welcome. You too. Bye-bye.
[CUSTOMER][POSITIVE] Thank you. Bye.