AccountId: 011433970860
ContactId: 5aea33e8-585a-4a9c-a407-9e1ba136045f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 211639 ms
Total Talk Time (AGENT): 100819 ms
Total Talk Time (CUSTOMER): 71623 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/03/5aea33e8-585a-4a9c-a407-9e1ba136045f_20250203T19:30_UTC.wav
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[AGENT][NEUTRAL] Contacting APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], we received a denial for a claim.
[AGENT][NEUTRAL] Yes, with whom am I speaking, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Oh, yes, I, what, what is the policy number that we're looking at today?
[CUSTOMER][NEUTRAL] Um, policy number, hold on.
[CUSTOMER][NEUTRAL] Policy number 01874106.
[AGENT][NEUTRAL] Thank you. And the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] Uh, her date of birth is [PII].
[AGENT][POSITIVE] OK, thank you. And uh you received a
[AGENT][NEUTRAL] Uh, I'm sorry, I do have to ask for a callback number in the event that we're disconnected. Yeah.
[CUSTOMER][NEUTRAL] Then I am.
[CUSTOMER][NEUTRAL] Um, callback number is [PII].
[AGENT][NEUTRAL] Thank you. And what is that date of service that we're looking at?
[CUSTOMER][NEUTRAL] [PII]. The total bill.
[CUSTOMER][NEUTRAL] It's $466.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And um
[AGENT][NEUTRAL] for [PII].
[CUSTOMER][NEUTRAL] It's only for one, yeah, it's only for one code. Do you need the claim number?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, does it end in 6472?
[CUSTOMER][NEUTRAL] Yes, that's, that's the one.
[AGENT][NEUTRAL] OK, and then what, uh, you said that there was 11 CPT code that you wanted to, you had a question on?
[CUSTOMER][NEGATIVE] Yeah, we received a denial for code 99203 with a modifier 25 for the office visit. It says non-covered.
[CUSTOMER][NEUTRAL] So I wanted to know why the office visit is not covered.
[AGENT][NEUTRAL] Yes, um, the policy doesn't, uh, the policy doesn't cover office visits at all. Um, it, it covers treatment within the physician's office, but it never covers the office visits. And so, um, whenever we receive something like that, you're, you're always gonna receive that, uh, denial, um.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] For uh an office visit. It doesn't matter whether it's a specialist or uh whether it's cancer treatment or, well, it's, it just depends, um, but, but office, office visits just in general are not gonna be covered.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] And that's, that's why you received that denial code.
[CUSTOMER][NEUTRAL] Um, so it's like,
[CUSTOMER][NEUTRAL] I see. So is, is it like uh an exclusion on the plan and something that we can bill the patient?
[AGENT][NEUTRAL] Well, it, I can't tell you to bill the patient, but it is, it is an exclusion on this plan. Um, so it's, so the only thing I can really, it's the exclusion, yeah. So the only thing I can really tell you is that, um, uh, you know, that's, we met our con contractual obligation with that, with that check that we sent you. Anything else and be above and beyond that, you may want to talk to the insured.
[CUSTOMER][NEUTRAL] It's an exclu exclusion on this plan, OK.
[CUSTOMER][NEUTRAL] OK, um, can you give me a reference number?
[AGENT][NEUTRAL] Yes, my name is [PII]. The first letter of my last name is [PII]. We're gonna use that today's date as a reference. Now is there anything else at all that I can help with?
[CUSTOMER][POSITIVE] Uh, no, that's it. Thank you very much.
[AGENT][POSITIVE] OK, thanks for contacting AP have a good.