AccountId: 011433970860
ContactId: 6ab29fea-6c19-4d68-b200-e08366559aea
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 847219 ms
Total Talk Time (AGENT): 289456 ms
Total Talk Time (CUSTOMER): 289644 ms
Interruptions: 6
Overall Sentiment: AGENT=0.2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/6ab29fea-6c19-4d68-b200-e08366559aea_20250207T15:46_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Uh, yes, good morning. My name is [PII]. I'm calling from provider office to taking some claim status. Can you help me?
[AGENT][NEUTRAL] Sure, I can verify claim status for you. And [PII], what is that policy number, please?
[CUSTOMER][NEUTRAL] 023243 03
[AGENT][POSITIVE] I apologize, say that one more time for me, please.
[CUSTOMER][NEUTRAL] Yeah, sure. 023-24303.
[AGENT][NEUTRAL] OK, thank you. Give me a moment. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, yes. The callback number is [PII].
[AGENT][NEUTRAL] OK. And the patient's name, date of birth?
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, and what was the date of service and amount of the charge?
[CUSTOMER][NEUTRAL] Uh hello.
[AGENT][NEUTRAL] Yes, ma'am. What was the date of service and amount of the charge?
[CUSTOMER][NEUTRAL] I can.
[CUSTOMER][NEUTRAL] Yes, sure. So that also service is [PII].
[AGENT][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello, can you hear me?
[AGENT][NEUTRAL] Uh, yes, ma'am. You're cut off on the date and the amount of charge.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Uh, OK. Uh, yes, I'm gonna repeat it. Uh, like the date of service is [PII], no, no, year [PII] and the bill amount $1,907 even.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Con, sir?
[AGENT][NEUTRAL] You said data uh data service [PII], is that correct?
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] No, no. [PII].
[AGENT][NEUTRAL] [PII]. OK. 1.
[CUSTOMER][NEUTRAL] I think.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] And you're calling from?
[CUSTOMER][NEUTRAL] I'm calling from provider office.
[AGENT][NEUTRAL] And the name of the provider's office?
[CUSTOMER][NEUTRAL] Uh, it is, um, Reading Hospital.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm showing that claim process is not a covered diagnostic test. Uh, the patient's policy has a diagnostic benefit, but it covers for MRI, CT, or a colonoscopy. So the diagnostic test performed is not covered.
[CUSTOMER][NEUTRAL] Uh, sorry, can you repeat it why this claim was denied it, diagnosed it?
[AGENT][NEUTRAL] It processed as is not a covered diagnostic test and the patient's policy covered diagnostic test or MRI, CT or colonoscopy.
[CUSTOMER][NEUTRAL] Uh, not covered. Can you spell out the diagnosis.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Can you spell out?
[AGENT][NEUTRAL] Spell what? I'm sorry.
[CUSTOMER][NEUTRAL] BI
[AGENT][NEUTRAL] Are you telling me, asking me to spell diagnostic, D I A N O S T I C?
[CUSTOMER][NEUTRAL] Yes, right.
[AGENT][NEUTRAL] Diagnostic.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Diagnostic test, right?
[AGENT][NEUTRAL] Correct, it's not covered.
[CUSTOMER][NEUTRAL] Uh, not covered diagnosis that, uh, so like, uh, the, uh, these services are covered MRI, right?
[AGENT][NEUTRAL] Uh, only comes for MRI, CT, uh, CT or colonoscopy. Those are only covered diagnostic tests under this patient's policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, so, uh, this, uh, this patient policy, um, like covered, uh, MRI and?
[AGENT][NEUTRAL] MRI, CT, and colonoscopy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, city and then can you spell out the name is?
[AGENT][NEUTRAL] Spell out what? colonoscopy?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] C O L O N O S C O P Y colonoscopy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, handle only MRI and CT scan, right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Allow me one minute, OK?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Please allow me one minute, OK?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh hello, please allow me one minute, OK?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh hello, can you hear me?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, hold on one minute.
[AGENT][NEUTRAL] OK, Ms. [PII], is there anything else I can assist you with today?
[CUSTOMER][POSITIVE] Oh yes
[CUSTOMER][NEUTRAL] Uh, OK. And I'm checking on my system and the diagnosis code bill like I30.9, right? This code not related to diagnosis test.
[CUSTOMER][NEUTRAL] Why the claim are denied?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] As I stated, the claim process is not a covered diagnostic test. If you do not agree with the claim decision, you have up to 180 days from the time the claim was processed to submit an appeal.
[CUSTOMER][NEUTRAL] Uh, but the
[CUSTOMER][NEUTRAL] OK, OK. I understand, but the, uh, like the diagnosis code are not related to diagnostic test.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, so we need to, uh, send this claim to following and, uh, resubmit a claim with appropriate, uh, CPT code.
[AGENT][NEUTRAL] No, ma'am, that's not what I stated. I stated that you have a right to submit an appeal. You have up to 180 days from the time the claim was processed to submit an appeal.
[CUSTOMER][NEUTRAL] Yes, yes, ma'am. I, I, I, I can understand, but like uh the building diagnosis code are correct.
[AGENT][NEUTRAL] Well, I, like I said, you can submit an appeal. I cannot, as I'm only telling you how the claim was processed. If you do not agree with the way the claim was process, you can submit an appeal to our office.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh, so, uh, uh, OK, OK. So, uh, OK, we, uh, submitted a medical records.
[CUSTOMER][POSITIVE] Absolutely
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh hello, can you hear me?
[AGENT][NEUTRAL] I can.
[CUSTOMER][NEUTRAL] Yeah, so, uh, we need to send a medical records, right? Or to process, uh,
[AGENT][NEUTRAL] Uh, you need to submit an appeal. You can submit a letter stating the reason for your appeal, and if you have any additional documents that we can review, you can attach that as well.
[CUSTOMER][NEUTRAL] So we need to uh submit the appeal with uh medical records, right?
[AGENT][NEUTRAL] I'm explaining you can submit an appeal letter stating the reason for the appeal, and if you have additional documents such as medical records, you can submit that for review.
[CUSTOMER][NEUTRAL] Uh hello, can you hear me?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So please, uh, send, yeah, please send the, uh, a letter uh through my fax.
[AGENT][NEUTRAL] Uh, you can mail it or fax it and let me know when you're ready I can give you our fax number.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh uh hello.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, OK. Uh, so please, I'm inform you that we do not have any appeal letters. So please, uh, you can, uh, uh, uh, fax to a appeal letter on my fax number.
[AGENT][NEUTRAL] As I said, you can fax it or you can mail it. Do you want the fax number to submit an appeal?
[CUSTOMER][NEUTRAL] Uh, ma'am, please try to understand. We need to, uh, like a appeal letter. So please do you send an appeal letter on my fax number? OK.
[AGENT][NEUTRAL] No, we do not send an appeal letter. If you are disagreeing with how the claim was processed, then you will need to submit an appeal letter to our company stating the reason for the appeal. We do not send appeal letters.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] This
[CUSTOMER][NEUTRAL] OK, please, uh, provide, yeah, OK, provide me your uh mailing address.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII], OK, [PII]
[CUSTOMER][NEUTRAL] Because.
[CUSTOMER][NEUTRAL] Can you repeat it? Uh, uh, [PII], right? And that's uh [PII], right?
[AGENT][NEUTRAL] No, ma'am, that's not what I stated, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK. Uh, can you spell out the city name? It is [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] OK, right.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and the zip code, can you provide me again?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] Please provide me and the time the finding is 180 days, right?
[AGENT][NEUTRAL] 180 days from the time the claim was processed, which was [PII]. So you've actually passed the time for an appeal, but you can submit an appeal.
[CUSTOMER][NEUTRAL] But the uh appeal timely filing is passed out.
[AGENT][NEUTRAL] Correct. You can still submit an appeal. It can be reviewed, but there's usually up to 180 days from the time the claim was processed to submit an appeal.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Uh, so like now we submit an appeal, uh, like you only you not, uh, like the, uh, considered to a reconsideration, right?
[AGENT][NEUTRAL] We can review
[CUSTOMER][NEUTRAL] OK. Thank you. And please provide me the reference number.
[AGENT][NEUTRAL] We do not give reference numbers. Is there anything else I can assist you with today, Ms. [PII]?
[CUSTOMER][NEUTRAL] No, can you spell out your name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thank you so much. Have a great day. Bye-bye.
[AGENT][POSITIVE] You're welcome. Thank you for calling APL.