AccountId: 011433970860
ContactId: 579b4b19-8828-434c-8dc5-7f856fed82b9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 494170 ms
Total Talk Time (AGENT): 249622 ms
Total Talk Time (CUSTOMER): 140862 ms
Interruptions: 0
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/19/579b4b19-8828-434c-8dc5-7f856fed82b9_20250619T17:08_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] Sorry
[CUSTOMER][NEUTRAL] Hi, um, I had a question on, um, a billing that I think was submitted by my.
[CUSTOMER][NEUTRAL] Um, a facility that I saw that wasn't paid and I just want to see why.
[CUSTOMER][NEUTRAL] And I'm trying to log into the website and I'm not able to so I don't have details from you guys but I have the dates I can give you and we can check that way.
[AGENT][NEUTRAL] OK, well, I'll be more than happy to assist you. um, so it sounds like a claim was denied.
[CUSTOMER][NEUTRAL] I'm not even sure if it was denied or if it just was never submitted, yeah, I'm not sure.
[AGENT][NEUTRAL] Is that what's happening?
[AGENT][NEUTRAL] Oh, OK. Well, I can check for you. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Um, sure, [PII] and then [PII].
[AGENT][NEUTRAL] Thank you for that. [PII], may I have your policy number?
[CUSTOMER][NEUTRAL] Um, yes, it is 01927993.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify um your date of birth, mailing, and email address on file?
[CUSTOMER][NEUTRAL] Sure, [PII] um [PII], and I believe the email is [PII].
[AGENT][NEUTRAL] Yes, and thank you so much for verifying and all the information provided is a verification of benefits, not a guarantee of payment. And um may I have the date of service, I can check the claim, see if it's here for you.
[CUSTOMER][NEUTRAL] Can check the claim
[CUSTOMER][NEUTRAL] Yeah, the data service was [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And who's the provider?
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Um, what's the, like the house or the, like the facility that you went to?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Um, Saint Charles Health System and it's specifically Saint Charles Cancer Center.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] OK, so it looks like we did receive a claim, um,
[AGENT][NEUTRAL] Back in April, hold on one moment, let me get the information for you.
[AGENT][NEUTRAL] [PII] we received the claim, um, and it is from Saint Charles Medical Group. Um, let me see what happened with it.
[AGENT][NEUTRAL] OK, so it's not a cover, it's not covered um by the policy. It says benefits payable under the certificate are only those listed in the schedule of benefits. This is not a covered loss under the plan.
[CUSTOMER][NEUTRAL] But why is that if it's a deductible reimbursement plan essentially and it's against my deductible?
[AGENT][NEUTRAL] Well, it's not a deductible reimbursement policy. This is your secondary insurance, we pay towards your co-pay, deductible or co-insurance, but your secondary insurance has its own benefits, so we pay towards it.
[AGENT][NEUTRAL] If it's covered on the policy.
[CUSTOMER][NEUTRAL] Um, and why isn't covered?
[AGENT][NEUTRAL] Um, hold on, let's see. So, so we're billed for 99215, which is a place of service code. So this is like a doctor's office looks like from that code I'm assuming. So doctors.
[CUSTOMER][NEGATIVE] Yeah, it's a cancer.
[AGENT][NEUTRAL] So your secondary insurance is broken into inpatient, like after you're admitted into the hospital and then outpatient. Under outpatient, you don't have any coverage for the office setting.
[AGENT][NEUTRAL] In terms of when they bill for the facility, you have coverage for the, you could have coverage for the treatment because you have the office treatment rider. So how they billed us for this 99215 code, that's a place of service code, whereas if they would have billed us for whatever you got done, it could have been covered because we have the treatment, not where it was done.
[AGENT][NEUTRAL] That makes sense.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I think so. So I mean can they adjust then how it was sent in so that it's covered? I've just, I've never had something not be covered under one of my policies.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So it seems like there's maybe an error and how they were sending this in.
[AGENT][NEUTRAL] Yes, they can resubmit the claim or or file a corrected claim, um, but if they are billing for the, let me see if there's anything else for this day to see if they filed anything else or is this the only claim.
[CUSTOMER][NEUTRAL] For this day
[AGENT][NEUTRAL] And that was [PII]?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, the only claim. So they're only billing for the facility. They haven't billed us for anything that like the treatment that you've received, so.
[AGENT][NEGATIVE] If they bill for the treatment, it could possibly be covered, but that's why this one was denied because it's only, they're only billing for where you went, not what you got done.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, I guess I will.
[AGENT][NEUTRAL] And it
[CUSTOMER][NEUTRAL] Have there been any changes I guess to this plan over the years? It's just um with the plan with you guys it's.
[CUSTOMER][NEUTRAL] Like I said, my impression always has been that it's just a deductible reimbursement plan.
[CUSTOMER][NEUTRAL] And again I've never had something not be covered when it's under the deductible.
[AGENT][NEUTRAL] Now, this
[AGENT][NEUTRAL] There's been no changes in your plan. Um, you've had it since [PII]. Um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me click on this.
[AGENT][NEGATIVE] That's the only reason this was denied because they're not billing for what you received, they're billing for where you went, and there's no coverage for where you went, it's for the treatment.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Cause all you, I'm just looking through your claims, everything else, yeah, but these, I was just looking through your claims, everything else.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Unless it's being built for the place of service, everything else has been paid on.
[CUSTOMER][NEGATIVE] Right, I know that's why I feel like there's an issue with how they did this one.
[AGENT][NEUTRAL] Yeah, they can, they can um try to resubmit it if you like. Um, let's see if this is Saint Charles.
[AGENT][NEUTRAL] Yeah, that's what's happening because some of their other claims I'm looking at one from [PII]. That's what's going on because they billed for the same thing, 99213 and it was denied, but the
[AGENT][NEUTRAL] Other claims have not been. So yeah, they should, they should try to correct the claim. I am not guaranteeing, but you know, it's worth a try.
[CUSTOMER][NEUTRAL] So what should I ask them to do if they resubmit it, try to resubmit as what?
[AGENT][POSITIVE] The best thing to do is have them give us a call and verify your benefits so that they're clear on what to bill for.
[AGENT][NEUTRAL] Or what to file for.
[CUSTOMER][NEUTRAL] Oh, are we able to just call them while you're on to make sure they do that?
[AGENT][NEUTRAL] Uh, I mean, I mean, we can try, do they have long hold times?
[CUSTOMER][NEUTRAL] No, I just got off the phone with them.
[AGENT][NEUTRAL] OK. May I have a good contact number for them?
[CUSTOMER][NEUTRAL] Um, yes, let me get right back there.
[CUSTOMER][NEUTRAL] It is [PII] sorry [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII] no sorry yeah [PII].
[AGENT][NEUTRAL] All right, hold on one moment, OK?
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.