AccountId: 011433970860
ContactId: 6bd972a9-51c8-42ec-afc9-6c3412eeb185
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 803710 ms
Total Talk Time (AGENT): 300212 ms
Total Talk Time (CUSTOMER): 189282 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/6bd972a9-51c8-42ec-afc9-6c3412eeb185_20250513T12:02_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. My name is [PII]. I'm calling from a provider's office. I wanted to see if you could give me um a possible term date on this patient's insurance and also, um, if the coverage this is from [PII].
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] The EOBs we have is not billable to Medicaid because they're not giving us um permission as a PR to bill. Can you look into this for me?
[AGENT][NEUTRAL] Let me look at the policy number, [PII], what do we have?
[CUSTOMER][NEUTRAL] What I have is 0193.
[CUSTOMER][NEUTRAL] 0827.
[AGENT][NEUTRAL] 0827. Alright, let me pull that up.
[AGENT][NEUTRAL] All right. And then patient's name and date of birth?
[CUSTOMER][NEUTRAL] First name is [PII], last name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm sorry, I believe it's [PII].
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I couldn't see that well I apologize.
[AGENT][NEUTRAL] Uh, no, that's OK.
[AGENT][NEUTRAL] OK, so the member's insurance as far as medical did terminate [PII]. It was a different policy number, not the one that you gave me, but from that date forward, there's been no other active coverage. So the term date uh was [PII].
[CUSTOMER][NEUTRAL] OK, um, are you able to check claims for me?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What's the data service?
[CUSTOMER][NEUTRAL] OK, that data service.
[CUSTOMER][NEUTRAL] [PII] we submitted a claim for $235.
[AGENT][NEUTRAL] OK, so let's see.
[CUSTOMER][NEUTRAL] I know the card that he kept bringing in is from [PII] so I don't know if this claim that I have should have went somewhere else under a different policy number.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so we did get a claim for that date of service, uh, [PII], it looks like it was under a different policy number. Do you want that for your records?
[CUSTOMER][POSITIVE] Yeah, yes, that would be great.
[AGENT][NEUTRAL] OK, so the policy number was 02.
[AGENT][NEUTRAL] 344-576
[AGENT][NEUTRAL] And that is the policy number that did terminate on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, it looks like the claim was received and denied, stating outpatient treatment benefits provide, um, only when a covered person receives treatment in urgent room, urgent care facility, physician's office. So it looks like the place of service was not covered.
[CUSTOMER][NEUTRAL] OK, let me check that on our claim to see.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] And I can fax you the EOB also if you need it.
[CUSTOMER][NEUTRAL] OK, because it does look like place of service 21. I'm not sure.
[CUSTOMER][NEUTRAL] What that is, but the only um things that we have there on these EOBs that we have none.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] There's like an
[CUSTOMER][NEUTRAL] OA 18 on one and
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] But none with the PR or anything that we're able to submit, can you tell me what the um explanation code for the denial is on yours? Is it giving us.
[CUSTOMER][NEUTRAL] A PR responsibility.
[AGENT][NEUTRAL] No, it's, it's probably not going to. Let me look at what the EOB shows, but yeah, most of ours are not gonna show any.
[AGENT][NEUTRAL] Patient responsibility, but let me see here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see when we got this. Give me just uh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For a couple of different claims on that day too, it looks like.
[CUSTOMER][NEUTRAL] Yeah looks like he was a um.
[CUSTOMER][NEUTRAL] Observation patient.
[AGENT][NEUTRAL] Oh for that.
[AGENT][NEUTRAL] Sorry [PII], it's taking me a second to find the EOB.
[CUSTOMER][NEUTRAL] Oh, that
[CUSTOMER][POSITIVE] No, that's OK. I appreciate your help. It's like Medicaid is so strict on it.
[CUSTOMER][NEUTRAL] And if we would send it like it is.
[CUSTOMER][NEGATIVE] They wouldn't process it for the patient.
[AGENT][NEUTRAL] I mean, I'm clicking on the date. I don't understand why this claim number like coming up.
[AGENT][POSITIVE] Oh, here we go. OK. I'm like, oh my gosh.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. So explanation of benefits is just gonna show it looks like.
[AGENT][NEUTRAL] Procedure code, uh, remarks code, total benefits paid, it shows 0, and then it just gives the remarks as to why.
[AGENT][NEUTRAL] Um, so yeah, there's.
[CUSTOMER][NEUTRAL] What did the remarks say on that one?
[AGENT][NEUTRAL] So the remarks on here show the denial codes.
[AGENT][NEUTRAL] And states the outpatient treatment benefit provides an indemn indemnity amount when a covered person receives treatment in an emergency room, urgent care facility, physician's office, or a physical speech or occupational therapy facility.
[AGENT][NEUTRAL] Treatment in an outpatient hospital less than 18 hours is not covered by this policy. Please refer to section 5.
[AGENT][NEUTRAL] The medical test for this state of service is not a covered diagnostic test. Therefore, no benefit is payable for this claim. Covered tests include MRI, CAT scan, um, and it lists some other upper GI sleep study, echocardio, other studies that are covered.
[CUSTOMER][NEUTRAL] OK, so they do you think I would be able to fax medical records and.
[CUSTOMER][NEUTRAL] Or it's
[CUSTOMER][NEGATIVE] Just plain not payable.
[AGENT][NEUTRAL] It looks like it's just not payable under the patient's plan, this indemnity plan.
[AGENT][NEUTRAL] Um, I mean, you can always resubmit, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And then I can send this to you. I don't know if this is helpful for you, but most of the time, none of our, you know, we don't ever advise on the patient responsibility portion, so they never gonna say patient responsibility.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] That I've seen.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What I'll do is I will try to um
[CUSTOMER][NEUTRAL] Just document what what you have, you know, you have told me and.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'll try to put it back. I don't know if Medicaid.
[AGENT][NEUTRAL] Do you want me, did you want a copy of this one just for um your records or?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Um, it, yeah, it may, that could help, um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you want my fax number?
[AGENT][POSITIVE] Yeah, absolutely. What's that facts.
[CUSTOMER][NEUTRAL] OK, you could put it to my attention. The fax number is [PII].
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, [PII], so, yeah, give it about 5 minutes and you should have a copy of that. Uh, do you want the claim number for this also, just in case?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][POSITIVE] Oh, that would be great, yes.
[AGENT][NEUTRAL] OK, claim number for this was 353.
[AGENT][NEUTRAL] 8191.
[CUSTOMER][NEUTRAL] OK, and do you give call reference numbers?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Call references my name with my last initial and then today's date. My name again is [PII] and that is spelled [PII], last initial [PII], and then today's date.
[CUSTOMER][POSITIVE] OK, thank you so much, [PII]. I appreciate you checking into this for me.
[AGENT][POSITIVE] Yeah, not a problem. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Oh you as well thank you bye bye.
[AGENT][NEUTRAL] Uh bye bye.