AccountId: 011433970860
ContactId: 57da5ff5-3a4d-4f1e-957b-3e6a072ab6d5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 427899 ms
Total Talk Time (AGENT): 152225 ms
Total Talk Time (CUSTOMER): 150678 ms
Interruptions: 0
Overall Sentiment: AGENT=1.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/10/57da5ff5-3a4d-4f1e-957b-3e6a072ab6d5_20250110T21:16_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Yeah, hi, this is [PII] calling from Deesh Medical Group, checking on claims. Could you please help me with that?
[AGENT][POSITIVE] Yeah, I'd love to help you with some claims today, [PII]. Can I have your callback number?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] With the extension [PII].
[AGENT][NEUTRAL] [PII]. Perfect. Thank you. And the policy number for your patient?
[CUSTOMER][NEUTRAL] It's 022 consecutive 07928.
[AGENT][POSITIVE] Thank you. Give me a moment to get that all pulled up for you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Would you be able to verify for me, please, your patient's first and last name and date of birth?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Yeah, I'm so sorry. I'm, I'm so sorry. It's [PII].
[AGENT][POSITIVE] No worries.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's [PII], spelled [PII] and the date of birth is [PII].
[AGENT][POSITIVE] Wonderful, thank you so much and
[AGENT][NEUTRAL] Let's see
[AGENT][NEUTRAL] What is the date of service we want to look at?
[CUSTOMER][NEUTRAL] It's for [PII].
[AGENT][NEUTRAL] You said [PII] or [PII], I'm sorry.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], got you. And the total bill amount, my friend?
[CUSTOMER][NEUTRAL] Uh, it's $371 even.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] See
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Could you verify the facility name on this?
[CUSTOMER][NEUTRAL] DuPage Medical Group.
[AGENT][POSITIVE] Perfect. It looks like I have it right here. I am showing that.
[AGENT][NEUTRAL] Your
[AGENT][NEUTRAL] Claim was received [PII]. It was processed [PII].
[AGENT][NEUTRAL] I have the claim number listed as 3414.
[CUSTOMER][NEUTRAL] Hey
[AGENT][NEUTRAL] 937.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And I do show that the claim had benefits payable with a $1.97 and then it also had a denial code on it. The denial code stated that um office visits are not covered by the above number policy, and it did fall on procedure code 99204.
[AGENT][NEUTRAL] And then as far as the benefits payable, um, I have a check number of 1834426.
[CUSTOMER][NEUTRAL] Uh, uh, actually, I'm so sorry. Uh, actually, for the CPT code 99204 is not covered by the member, uh, policy, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Uh, give me one second. I'm just noting it.
[AGENT][POSITIVE] No, take your time.
[CUSTOMER][NEUTRAL] It's not covered by
[CUSTOMER][NEUTRAL] Member plan.
[CUSTOMER][NEUTRAL] OK. So, uh,
[CUSTOMER][NEUTRAL] Actually, um, here, as per the claim form, we find that the patient was, uh, the 99204 is an office visit and, but, uh, without having an office visit, how can a person had an, uh, like in um
[CUSTOMER][NEUTRAL] A service of 81003.
[CUSTOMER][NEUTRAL] Uh, which is urinalysis.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, because, um, because, uh, I have a question, uh, without having an appointment with a provider like.
[CUSTOMER][NEUTRAL] 30 to 45 minutes. How can the person had, uh, like the member had the
[CUSTOMER][NEUTRAL] A treatment of for the service.
[AGENT][NEUTRAL] Yeah, so we're just a supplemental policy, so we're not, you know, they're major medical, we just supplement, and it looks like their policy covers treatment in an office setting, but not those administrative charges, so the consultations because that's not considered treatment. So that's why it was able to give you benefits payable for the treatment done, the 81003, but not.
[AGENT][NEUTRAL] Um, not the 99 number.
[CUSTOMER][NEUTRAL] Office.
[AGENT][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, so, uh, is this our calls and the patients responsible?
[AGENT][NEUTRAL] Because we're secondary insurance, we're not allowed to determine patient responsibility.
[CUSTOMER][NEUTRAL] So, um, we can bill this balance to the patient now because the member doesn't have any other insurance and as per the member plan itself, it got denied.
[AGENT][NEUTRAL] Yeah, so I guess that's up to the providers group, but APL can't determine that.
[CUSTOMER][NEUTRAL] OK. Sure. Thank you for it. So, and could you please help me with the
[CUSTOMER][NEUTRAL] Mm, give me one second.
[AGENT][NEUTRAL] Yeah, let me know.
[CUSTOMER][NEUTRAL] Yeah, thanks for being on hold.
[AGENT][POSITIVE] No worries.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yup. OK. Thanks for that. And if you don't mind, could you please help me with your name? I just missed it. It's like
[AGENT][NEUTRAL] Yes, my name is [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yup. Thank you, uh, and, and could you please help me with the call reference number for this number?
[AGENT][NEUTRAL] Oh yeah, it's gonna be my name [PII], and today's date.
[CUSTOMER][POSITIVE] Yeah. OK. Thank you, [PII]. Have a great day. Bye now.
[AGENT][POSITIVE] Hey, it's my pleasure, [PII], you take care.
[CUSTOMER][NEUTRAL] You too. Bye now.
[AGENT][NEUTRAL] Bye bye.