AccountId: 011433970860
ContactId: 6b4dfea7-6098-4841-8e91-9e7e6e39e010
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 574549 ms
Total Talk Time (AGENT): 184404 ms
Total Talk Time (CUSTOMER): 232712 ms
Interruptions: 3
Overall Sentiment: AGENT=0.9, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/15/6b4dfea7-6098-4841-8e91-9e7e6e39e010_20250515T21:25_UTC.wav
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[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah. Hi, [PII]. This is [PII] and last initially [PII], and I need a claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status, [PII], and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] One.
[AGENT][NEUTRAL] OK, and may I have the member's policy number?
[CUSTOMER][NEUTRAL] Policy number is going to be.
[CUSTOMER][NEUTRAL] 01897883
[AGENT][POSITIVE] Thank you. And may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Contact number is [PII].
[AGENT][NEUTRAL] Thank you. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] First name is [PII], last name is [PII].
[CUSTOMER][NEUTRAL] Date of birth [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and total bill for the claim?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] [PII] charge amount is $821.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And can you verify the name of the facility on the claim?
[CUSTOMER][NEUTRAL] Uh, McPerson Medical and Diagnostic LLC.
[AGENT][NEUTRAL] Thank you, and I'm showing that we received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 359.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] 8678.
[AGENT][NEUTRAL] And on [PII], I'm sorry, [PII], the claim was denied.
[AGENT][NEUTRAL] Because office visits are not covered on the policy.
[CUSTOMER][NEUTRAL] Office visit, visit is what?
[AGENT][NEUTRAL] Office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] For this policy. So, basically, you want to say that like under the patient's plan of his visit, visit is not covered?
[AGENT][POSITIVE] Correct, that's what I'm explaining. Correct.
[CUSTOMER][NEUTRAL] OK, one second, let me just check that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] right
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] According to the.
[CUSTOMER][NEUTRAL] Primary insurance.
[CUSTOMER][NEUTRAL] the claim.
[CUSTOMER][NEUTRAL] Well
[AGENT][NEUTRAL] OK, so the primary
[CUSTOMER][NEUTRAL] So can you please uh tell me which, which CD code is not covered?
[CUSTOMER][NEUTRAL] Is it 99215.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] She
[AGENT][NEUTRAL] 99215 is not covered by the policy. Office visits aren't covered. Let me get the other denials for you. Hold on one moment.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] All the other three codes, 7,683,158,340 and 99459 were all denied.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Um, because the
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Insured primary.
[CUSTOMER][NEUTRAL] The remaining courses are paid, just uh
[CUSTOMER][NEUTRAL] Yeah, remaining courses are, are, are already paid. Just tell me 58,340.
[AGENT][NEUTRAL] As I stated, that code is denied because the primary insurance provided full benefits.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Because this code is uh processed as deductible.
[CUSTOMER][NEUTRAL] So you are not covering the deductible?
[AGENT][NEUTRAL] Procedure code 76831 is not for deductibles.
[CUSTOMER][NEGATIVE] No, no, no.
[CUSTOMER][NEUTRAL] 58,340. This uh CPD code processed in deductible.
[AGENT][NEUTRAL] So this
[CUSTOMER][NEUTRAL] So, when we submit the claim to Skur.
[AGENT][NEUTRAL] If you'll allow me to speak, sir, so I can answer your questions.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Code 58,340 is not for
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, go ahead.
[AGENT][NEUTRAL] Code 58,340 is not for a deductible. It's for a catheterization.
[AGENT][NEUTRAL] That code
[AGENT][NEUTRAL] From what we received, primary paid full benefits towards that code. If you have an explanation of benefits that shows that primary did not, then we can reprocess.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That, that, uh, this is the issue that I uh want to understand you is.
[CUSTOMER][NEUTRAL] Insurance process this CBD code 58,340 in deductible.
[AGENT][NEUTRAL] What do you mean in deductible? What do you mean by that?
[CUSTOMER][NEUTRAL] Like, like, uh, uh, all the CBD code, insurance pay the claim except 99215, which is paid and insurance left copays $75. Got it. And remaining codes are paid except 58,340. Insurance.
[CUSTOMER][NEUTRAL] This CBD code processed in deductible like insurance did not pay for this CBD code.
[CUSTOMER][NEUTRAL] Insurance allowed $186 and insurance process that would be.
[AGENT][NEUTRAL] OK, so as I stated, if you have not
[AGENT][NEUTRAL] Sir, in order for me to assist you, I'm gonna have to speak. So, as I was trying to explain to you, if you have an explanation of benefits that shows that the full amount was not applied to code 58,340, you can resubmit that explanation of benefits and we can reprocess the claim. From what we received, it showed that primary insurance paid full benefit.
[CUSTOMER][NEUTRAL] Uh-huh
[CUSTOMER][NEUTRAL] OK, go ahead.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK. So, but, OK. So 4 99215.
[CUSTOMER][NEUTRAL] Of visit is, you are like APL is not covering office visits.
[AGENT][NEUTRAL] For this patient's policy, office visits are not covered.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The patients. Can I get the patient's plan name?
[AGENT][NEUTRAL] Yes, this is a Medlink.
[AGENT][NEUTRAL] Supplemental gap insurance policy?
[CUSTOMER][NEUTRAL] Supplementh. Can you spell?
[AGENT][NEUTRAL] Gap, GAP like Paul.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That's the name of the policy. It's a Medlink supplemental gap insurance policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Gap policy OKga Li policies.
[AGENT][NEUTRAL] Gap insurance policy.
[CUSTOMER][NEUTRAL] The insurance one.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, [PII], thank you so much for your time and information. And uh can I get your name and reference number?
[AGENT][NEUTRAL] Yes, my name is [PII]. The first initial of my last name is [PII], and there's no call reference number, but you can use my name and today's date.
[CUSTOMER][POSITIVE] All right. OK. Thank you so much, [PII]. Have a nice day, bye.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] Thanks for calling APL. Have a good day. Bye-bye.