AccountId: 011433970860
ContactId: 60eb4eaa-e35a-4ec9-b320-4da262f995cb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1572500 ms
Total Talk Time (AGENT): 446458 ms
Total Talk Time (CUSTOMER): 479674 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/13/60eb4eaa-e35a-4ec9-b320-4da262f995cb_20250113T20:17_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I'm calling to find out if you received some claims and if they've been processed for my client.
[AGENT][NEUTRAL] OK. Happy to check on some claims. Do you have their policy number?
[CUSTOMER][NEUTRAL] Yes, ma'am. It is.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] 418. 0, I think that's actually her social security number.
[CUSTOMER][NEUTRAL] [PII]. I just realized it now I'm like that's too many numbers for the cause she puts on your claim form Social Security or policy. So she put Social Security. Can you use that or do you want me to get her policy?
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] No, I can look it up by that. It was, it starts with [PII].
[CUSTOMER][NEUTRAL] Yes, [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, let me.
[AGENT][NEUTRAL] And if you don't mind, can I grab your first name and a callback number?
[CUSTOMER][NEUTRAL] [PII], and it's [PII].
[AGENT][NEUTRAL] Thank you, [PII]. Uh, what is the patient's name, first and last name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] All right. Let me try this again cause that didn't come up.
[CUSTOMER][NEUTRAL] I think it's under just let me go into the APL system I believe with you guys she's just under [PII].
[AGENT][NEUTRAL] Oh, there we go. OK.
[AGENT][NEUTRAL] Um, what is her date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, I found her.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so do we have any claim numbers to reference or a date or anything like that?
[CUSTOMER][NEUTRAL] No, all I have are.
[CUSTOMER][NEUTRAL] I have dates of service. The first one is for [PII] for Quest Diagnostics.
[AGENT][NEUTRAL] OK, let me do a search by date and see what I find here.
[AGENT][NEUTRAL] OK, so I don't show any claims on file date of service [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, the next one.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I just wanna make sure that you haven't received them because if she wants me to file claims and I don't wanna.
[CUSTOMER][NEUTRAL] File claims for something she doesn't remember what she's already submitted. The next, what can I, what can I tell you?
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Um, OK, this is a good one because
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEGATIVE] Yeah, I don't think I can even do this one cause this one.
[CUSTOMER][NEUTRAL] Is Baptist Health, but it has like
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] 26 2024
[CUSTOMER][NEUTRAL] For Baptist health.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, 2624.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Do you have her explanation of benefits from her primary by chance or?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I'm sure I do, but
[AGENT][NEUTRAL] Cause there's a couple different.
[CUSTOMER][NEUTRAL] I know the total amount billed was 2,736.
[AGENT][NEUTRAL] So there's a couple of different claims here. I'm sorry. I'm trying to differentiate like what is what here.
[AGENT][NEUTRAL] Because I do show a claim for 26 that was submitted and part of it was paid.
[AGENT][NEUTRAL] But there is a billed amount for 20376 and it says denied due to it was a previously submitted claim, so I'm trying to find the previously submitted.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, she basically sent me a statement from [PII], but there's like.
[CUSTOMER][NEUTRAL] I can see 2 X-rays.
[CUSTOMER][NEUTRAL] Which were different dates on.
[AGENT][NEUTRAL] Yeah, cause 2376.
[AGENT][NEUTRAL] Yeah, so the only other claim I see.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] The amount doesn't match, it's 2324.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] 2324.
[AGENT][NEUTRAL] What's the bill amount?
[CUSTOMER][NEGATIVE] Yeah, I don't, she didn't send me that one.
[AGENT][NEUTRAL] For
[AGENT][NEUTRAL] So that
[AGENT][NEGATIVE] That shows denied. It says major it says benefits are only payable if major medical um pays if your major medical later pays, please send explanation of benefits.
[AGENT][NEUTRAL] But the claim that I did find with that matching amount for the 2,376.
[AGENT][NEUTRAL] It just shows declined for duplicate. Let me see if I can search by the procedure code.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] So based off of that procedure code and the duplicate one that I'm seeing, it looks like there was a benefit payment since for 5:30-27. Do you know what her the residual was after primary?
[CUSTOMER][NEUTRAL] Um, this one, she had a balance due of.
[CUSTOMER][NEUTRAL] 134 41, so it's something different, I guess.
[AGENT][NEUTRAL] Yeah I mean that's the only thing I can find that links up based off of the amount data service and procedure code.
[CUSTOMER][NEUTRAL] OK. Um,
[CUSTOMER][NEUTRAL] OK, I guess I will resubmit that one then because I guess that one's not there. OK, then I have another one for the date of services [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The provider is Metaquip.
[CUSTOMER][NEUTRAL] It was for a knee brace.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I thought I submitted that.
[AGENT][NEUTRAL] So I do see, yeah, I see a claim for Mequip Inc.
[AGENT][NEUTRAL] And a benefit payment was made.
[AGENT][NEUTRAL] On part of it, it looks like it's OK for 10439.
[CUSTOMER][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] Yeah, that's it.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So that claim was received and paid.
[CUSTOMER][NEUTRAL] And who
[CUSTOMER][NEUTRAL] To her
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEGATIVE] So she should have gotten reimbursed for the 10439.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Do you know when they, when the check was sent?
[AGENT][NEUTRAL] Let me see here.
[CUSTOMER][NEUTRAL] I'm sorry.
[AGENT][POSITIVE] No, that's OK. You're totally fine.
[AGENT][NEUTRAL] Um, so it looks like I'm showing claim is processed [PII].
[AGENT][NEUTRAL] So, uh, the check would have been issued on the [PII] and then mailed shortly after.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] To her.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so I'll let her know that when she was paid.
[CUSTOMER][NEUTRAL] And this is Medicorp.
[CUSTOMER][NEUTRAL] Yeah, cause I remember now that I see it I I remember filing that claim for her on the, on the, well, I filed the claims for my clients. What can I tell you?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] And this one looks familiar too, but I'm not 100%. I think I did, but I'm not 100%. This one, the date of service is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And it's Miami Cancer Institute.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] And the, the total charges was 1940.
[AGENT][NEUTRAL] OK, yeah, that's
[CUSTOMER][NEUTRAL] And her responsibility was 230, 280.
[AGENT][NEUTRAL] This was submitted a couple of times it looks like.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] So looks like.
[AGENT][NEUTRAL] The original claim was denied, but then it looks like it was resubmitted.
[AGENT][NEUTRAL] But it's still showing.
[AGENT][NEUTRAL] So it looks like the claim denied saying that benefits are only payable for condition other than sickness or injury.
[AGENT][NEUTRAL] It was submitted.
[CUSTOMER][NEUTRAL] Yeah, because I have it here I can see here where I submitted it.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And that was for.
[CUSTOMER][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Yeah, that one I submitted the EOB.
[AGENT][NEUTRAL] There were a few procedure codes I guess submitted within that.
[CUSTOMER][NEUTRAL] 9424. Yes, 9424. So what that was for was she had breast cancer and she had surgery and then she had the tattoo.
[CUSTOMER][NEUTRAL] So that's not covered?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like, yeah, not covered.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] I mean, it's saying benefits not payable for condition other than sickness or injury.
[CUSTOMER][NEGATIVE] That is sickness. That's cancer. OK.
[CUSTOMER][NEUTRAL] It's breast cancer, so they remove your nipple.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] And breast, she had breast removal.
[CUSTOMER][NEUTRAL] And then she had an implant and then the tattoo.
[CUSTOMER][NEUTRAL] The nipple.
[CUSTOMER][NEUTRAL] So I guess, I don't know. I mean, it's covered by the insurance, the primary covered it.
[CUSTOMER][NEUTRAL] The insurance, UnitedHealthcare covered it, cause it's part of the
[AGENT][NEUTRAL] Do you know?
[AGENT][NEUTRAL] So there on this particular yeah I mean on this particular claim there were quite a few things submitted and there's different denial reasons do you know what they would have billed it as under the procedure code?
[CUSTOMER][NEUTRAL] I don't even know what this
[CUSTOMER][NEUTRAL] Um, hold on one moment, let me see, let me pull up.
[AGENT][NEUTRAL] Because some of the denials say like um insured major medical provided full benefits, so there was nothing additional payable from us.
[CUSTOMER][NEUTRAL] No, yeah, no, no, it was definitely not full because I provided the EOB and it showed that.
[CUSTOMER][NEUTRAL] Um, the deductible is applicable and it was 232. Let me see, let me tell you what it says. I don't know.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] OK, the codes for this were CAD 995.
[CUSTOMER][NEUTRAL] But I don't, that's the claims code. I don't know.
[AGENT][NEUTRAL] OK, let me see.
[CUSTOMER][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] MPP 0, it was clearly on the
[CUSTOMER][NEUTRAL] On the EOB I submitted.
[CUSTOMER][NEUTRAL] On page 6.
[CUSTOMER][NEUTRAL] And it shows the total bill amount was 1940.
[CUSTOMER][NEUTRAL] Um, the insurance paid 93,120, and her responsibility was 23,280.
[CUSTOMER][NEUTRAL] Um let me see now.
[CUSTOMER][NEUTRAL] And then she, oh, and I did put ICD code Z42.1.
[CUSTOMER][NEUTRAL] That's what the provider gave us.
[AGENT][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm sorry.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Yeah, so the only, there's only two things that I see on here that are just asking for like a diagnosis code. The provider for that is Ameriath Florida.
[AGENT][NEUTRAL] And so that portion of the claim that was denied is asking for diagnosis codes for, it looks like labs. The CAD 995, I don't see on this particular explanation of benefits under the procedure codes, um.
[AGENT][NEUTRAL] [PII] was he.
[CUSTOMER][NEUTRAL] No, so this is
[CUSTOMER][NEUTRAL] Yeah, no, so this, the 23,280 is for the Miami Cancer Institute.
[CUSTOMER][NEUTRAL] That's who I show it's for. It's for the
[CUSTOMER][NEUTRAL] Um, the tattooing.
[AGENT][NEUTRAL] Yeah, so I don't see anything with that.
[CUSTOMER][NEUTRAL] And it was submitted because I have the confirmation that I submitted it on, hold on, let me see.
[CUSTOMER][NEUTRAL] Data source of 94.
[CUSTOMER][NEUTRAL] And here it is right here, and here's the confirmation.
[CUSTOMER][NEUTRAL] Um, let me see.
[CUSTOMER][NEUTRAL] I have a confirmation number of the claim being submitted.
[AGENT][NEUTRAL] Well, it was
[AGENT][NEUTRAL] What was the
[CUSTOMER][NEUTRAL] O S O S C
[CUSTOMER][NEUTRAL] 89,720
[AGENT][NEUTRAL] Let me look at that.
[AGENT][NEUTRAL] Yeah I mean it looks like from what I can see um on that claim number because I have a claim number for that confirmation that you gave me um so it shows denied so it's not reading the.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's not paying on any of the, you know, the tattooing reconstructive, it looks like it's not reading that as sickness or injury itself, the procedure cause it says policy provides no benefits for treatment other than sickness or injury.
[CUSTOMER][NEUTRAL] Even though it's part of a reconstruction of a breast.
[CUSTOMER][NEUTRAL] That obviously can't be done at the same time, you have to wait. And I only know this because my mother-in-law went through it as well. Um.
[CUSTOMER][NEUTRAL] So you, you can't have it done the same day you have the reconstruction, you have to wait till you heal.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And I guess maybe that's why they wouldn't consider, but it's part of the reconstruction process like.
[CUSTOMER][NEUTRAL] Do you understand what I'm saying? Like,
[AGENT][NEUTRAL] Yeah. Yeah, no, definitely.
[CUSTOMER][NEUTRAL] You know, like,
[CUSTOMER][NEUTRAL] Like, yeah, I understand she didn't have it the day of the surgery, but you can't.
[CUSTOMER][NEUTRAL] Um, because you have to wait and make sure you heal properly and everything goes accordingly before you have that done.
[CUSTOMER][NEUTRAL] So there's no way to, I don't know how to.
[AGENT][POSITIVE] You can appeal it.
[CUSTOMER][NEUTRAL] Like dispute it, like, appeal it, thank you. I can't think of the word.
[AGENT][NEUTRAL] Yeah, you can you can, yeah, you can appeal it within 180 days of the decision and the claim was processed [PII], so you're still well within that time frame to appeal it.
[CUSTOMER][NEUTRAL] So what do I have to do?
[AGENT][NEUTRAL] Um, so it would need to be, um, in writing, um, it's a letter to us stating the reason for the appeal of the claim, and I can give you the claim number if you, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Please.
[AGENT][NEUTRAL] And then you would, yeah, the claim number is 353.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 7916.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, so yeah, just a written notice stating the reason for the appeal while you're appealing the decision and then mail that to us at [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 950, yeah.
[CUSTOMER][POSITIVE] And let me ask you, I'm sorry.
[CUSTOMER][NEUTRAL] I'm sorry, can I resubmit it through the portal or no?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Since it's an appeal.
[AGENT][NEUTRAL] The appeal
[CUSTOMER][NEUTRAL] Cause it's just easier for my life too. Oh, it has to be mailed to the appeal?
[AGENT][NEUTRAL] The appeal has to be in writing, yeah.
[CUSTOMER][NEUTRAL] No, no, I understand, but I can have her do a letter, and then if I could submit it through the portal or no, that's not allowed.
[AGENT][NEGATIVE] No, unfortunately, it has to be uh put in the mail.
[CUSTOMER][NEGATIVE] Come on APL, get with the program. The mail stinks. It's like 100 days to get something.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK. So um let me get the address. [PII]. Mhm.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] And it's attention appeals.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it's [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] OK, so attention appeals APL [PII] date of service [PII]. No, I'm sorry, that's the date it was denied.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And I have the date of service because it's here [PII] and the claim number is 353-7916.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, so that one I have to send an appeal. The other one was paid and then the other ones.
[CUSTOMER][NEGATIVE] We're not, um, were never received or they didn't bill directly Baptist and Quest.
[AGENT][NEUTRAL] Yeah, we didn't.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is there anything else I can check on?
[CUSTOMER][NEUTRAL] OK. So,
[CUSTOMER][POSITIVE] No, that's it for today. Thank you so much.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. I hope you have a good rest of your day.
[CUSTOMER][POSITIVE] Thanks. You too. Bye-bye.
[AGENT][NEUTRAL] Bye bye.