AccountId: 011433970860
ContactId: 605f5d4a-65f8-4598-9b20-aeac502b537c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 444109 ms
Total Talk Time (AGENT): 219419 ms
Total Talk Time (CUSTOMER): 145554 ms
Interruptions: 2
Overall Sentiment: AGENT=1.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/27/605f5d4a-65f8-4598-9b20-aeac502b537c_20250327T19:04_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, [PII]. I'm calling to uh verify my coverage.
[AGENT][NEUTRAL] OK, well, I can help you with your coverage. Um, you want to like see if it's active still?
[CUSTOMER][NEUTRAL] Um, I know, I know it's active, but I tried to file a claim and it said that I don't have any coverage for, um, office visits.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For specialists, so that's what I wanted to check.
[AGENT][NEUTRAL] OK, well, I can definitely look into the claim with you. May I have your name and a good contact number?
[CUSTOMER][NEUTRAL] Sure. My name is [PII].
[CUSTOMER][NEUTRAL] My number is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have your policy number or the claim number?
[CUSTOMER][NEUTRAL] Yeah, the policy number is.
[CUSTOMER][NEUTRAL] I have a group number that's the same thing.
[AGENT][NEUTRAL] No, but I can use the group number to get to your policy.
[CUSTOMER][NEUTRAL] OK, great. 15297.
[CUSTOMER][NEUTRAL] Don't see it in the morning.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] It's under [PII], my husband.
[AGENT][NEUTRAL] And I believe I just located it and hold on one moment.
[CUSTOMER][POSITIVE] Great.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] All right, and I just need you to verify your date of birth and the mailing address on file.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] So my address, I mean, my date of birth is [PII].
[CUSTOMER][NEUTRAL] The address is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And um do you have the claim number or the date of service for the claim you like me to look at?
[CUSTOMER][NEUTRAL] Um, I don't, but it was the last claim I submitted. I believe the date of service was beginning of March sometime, maybe like the [PII] maybe. It was for my son.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, it's for your son. OK, hold on one second.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, this should just be the last one.
[AGENT][NEUTRAL] OK, I see it here. Hold on one moment, it's coming up now.
[AGENT][NEUTRAL] In [PII], OK.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so it was, it was denied because office visits are not covered on the policy. So, um, before I do that all the information provided is a verification of benefits, not a guarantee of payments.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So the policy is broken down into like inpatient and outpatient. So inpatient would be like if you all are admitted or something. Outpatient is like uh emergency room, urgent care, outpatient surgeries. It doesn't have coverage for some places charge for the facility, which is what this is, and then some places charge for the treatment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Some places charge all of it together. The policy itself doesn't have any coverage for the in-office coding, the in-office setting, but you do have the office treatment rider. So the treatment in the office could be covered up to that $6000 per calendar year, as long as it's not cosmetic.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Great. So how would that work? So I went to my son's, um, he fractured his foot. I went to an or, or, uh, visit where they, you know, did X-rays, put a boot on him, um, and I paid the $60 co-pay. So that $60 copay is not.
[CUSTOMER][NEUTRAL] Covered because it's not um it's an in-office visit, but the treatment of like the X-rays and the boot, that will be covered.
[AGENT][NEUTRAL] Right, so let, let me see what was included on this claim. Hold on one second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, so this is only for the, let me see what the other one was. There's 2 on here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the office visit denial is only for one part of the policy, uh, the claim. The other part, I mean there's no coding, it's like abbreviation, but the other part is asking for supporting documentation to evidence that an act of the accident or sickness. Supporting documentation can be an itemized bill with the diagnosis code.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Super bills, office notes, so we just need, we just need something so that we can prove medical necessity. So it can be a
[AGENT][NEUTRAL] The clinical note from the doctor, just has to have the diagnosis codes and the procedure codes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I'll ask when I go.
[AGENT][NEUTRAL] And then we'll continue reprocessing that part.
[CUSTOMER][NEUTRAL] Right. And what would that part cover whatever the um primary doesn't pay cause I also have primary insurance and that's what the um additional benefits that I sent in was for.
[CUSTOMER][NEUTRAL] Um, so what, what, um, would my plan be for for the difference, whatever the family doesn't cover?
[AGENT][NEUTRAL] No, no, so we pay towards the copay, deductible and co-insurance of covered charges after primary. So, if you have to pay like a co-pay, well, let me start here. Primary policy has its own benefits and then secondary has its own benefits. So if you pay a copay and it's something that's covered on primary, but it's not covered on your secondary, it, it wouldn't be.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, we can't pay out on it, but if it's something that is covered, we can reimburse you or if something still owed to the provider up to that $6000 a year, you know, we could pay out to the provider or both.
[AGENT][NEUTRAL] It just depends on what's left over after primary.
[CUSTOMER][NEUTRAL] Oh, OK. OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alrighty, well, was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] Like
[AGENT][POSITIVE] Alright, well thank you. Alright, so was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Yeah, so I just want to confirm I need to submit the claim again, but with, with the procedure codes and um.
[CUSTOMER][NEUTRAL] And the diagnosis code?
[AGENT][NEUTRAL] Yes, um, you don't have to submit the whole claim again. You can just whatever the document is that you're submitting for this, like if it's a bill, just submit the bill. Um, if you choose to use like office notes, just submit the documents.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so ask the doctor for a note that shows procedure and.
[CUSTOMER][NEUTRAL] Diagnosis.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, so I'll do that and add it to add it to the class.
[CUSTOMER][POSITIVE] Alright, thank you so much for explaining that to me. I appreciate your help.
[AGENT][POSITIVE] You're very welcome. Was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] Oh no, that's gonna be it.
[AGENT][POSITIVE] Alright, well, thanks so much for calling APL. I hope you have a great day.
[CUSTOMER][POSITIVE] Thank you you too bye bye.
[AGENT][POSITIVE] Thank you. Bye-bye.