AccountId: 011433970860
ContactId: 6deacbbe-82cd-43ea-b6f0-e99350de7084
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 880320 ms
Total Talk Time (AGENT): 380856 ms
Total Talk Time (CUSTOMER): 398448 ms
Interruptions: 7
Overall Sentiment: AGENT=0.6, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/03/6deacbbe-82cd-43ea-b6f0-e99350de7084_20250203T16:27_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling from Core View Surgery Center, and I just had a claim that was denied for not cover expense. I just wanted to confirm those benefits if you could.
[AGENT][NEUTRAL] Sure we could take a look at those benefits and then I'll double check that claim for you. um [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yes, not a problem, [PII].
[AGENT][NEUTRAL] Thank you. Do you have the policy number?
[CUSTOMER][NEUTRAL] Yes, that is 01611704 Mother Lima number 8.
[AGENT][NEUTRAL] All right, thank you. And uh what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that. See, uh, what was the, do you have that claim number by chance?
[CUSTOMER][NEUTRAL] I don't have the claim number, um, the ditch, OK, 331-2023 uh $4,133.
[AGENT][NEUTRAL] That's OK. uh, what was the date of service?
[AGENT][POSITIVE] OK, thank you one moment please.
[AGENT][NEUTRAL] OK, and that amount the $4,133 was that the amount before a major medical paid?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Do you have that remaining balance?
[CUSTOMER][NEUTRAL] Hi
[CUSTOMER][NEUTRAL] The probably give me a sec.
[AGENT][POSITIVE] OK, no worries, no worries.
[CUSTOMER][POSITIVE] On that, yeah, yeah, thank you.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh, actually, patient, uh, it was applied to patients deductible, so that would have been that.
[CUSTOMER][NEUTRAL] Charged the amount was it was the remaining balance.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] After primary mhm.
[AGENT][NEUTRAL] Got you alright one moment.
[AGENT][NEUTRAL] And then I'm so sorry, what was the name of the provider's office, [PII]?
[CUSTOMER][NEUTRAL] Uh, well, this claim was from Coral View Surgery Center. I can actually give you a because actually this one we were trying to do is file with secondary, but let me just pull back this claim and see because I think it was denied under the doctor's side and this would have been for the facility. Give me just a second.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Um, if you've got the tax ID, that would be great.
[CUSTOMER][NEUTRAL] Yeah, tax ID number is [PII].
[AGENT][NEUTRAL] OK, I think I found it. I think we've got it as Gastro Med LLC.
[CUSTOMER][POSITIVE] That is correct.
[AGENT][NEUTRAL] Take a look here. OK.
[AGENT][NEUTRAL] Well, maybe not. Let's see.
[CUSTOMER][NEUTRAL] Let me, let me pull it. I think I might be able to maybe get you a claim number on that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, it looks like they just called and.
[CUSTOMER][NEGATIVE] It's just very odd.
[CUSTOMER][NEUTRAL] Oh that's
[CUSTOMER][NEUTRAL] OK, I just had a note secondary deny policy provides no benefits for the treatment or condition other than sickness or injury as defined by the policy, but I don't have an actual denial letter on file.
[AGENT][NEUTRAL] That's OK. Um, I think I found it. I've only got one claim from that for that date of service, uh, from this provider, so gotta be this one.
[CUSTOMER][NEUTRAL] GastroMed and it was it was it 2370?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I think so. Let me get that pulled back up. Give me just a moment.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so yes, it looks like for two of those procedures we were missing the primary EOB, uh, showing what primary paid. Uh this is their secondary medical and then yes, uh, that one procedure code I can verify that one, but it does state that there are no benefits for the treatment of conditions other than sickness or injury as defined by the policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, which, uh, code was that?
[AGENT][NEUTRAL] Let's see, that was 45378.
[CUSTOMER][NEUTRAL] OK, so 4537 there were it was just pending primary EOB.
[AGENT][NEUTRAL] So the other two.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Correct, so the 432-51 and the 43239, uh, we were missing the primary EOB.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, uh, mhm.
[AGENT][POSITIVE] And I do have this EOB um I can definitely send that to you if you'd like [PII].
[CUSTOMER][NEUTRAL] OK, uh, yeah, and then could I because maybe could I use that to send back, would it be too late to send that UV now?
[AGENT][POSITIVE] Of course, no, there is no timely filing limit you are perfectly fine.
[CUSTOMER][NEUTRAL] OK, alright, so.
[AGENT][NEUTRAL] And this will have I can give you that claim number the claim number will be on the EOB but I can still go ahead and give it to you just in case.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, what is that?
[AGENT][NEUTRAL] It is 33.
[AGENT][NEUTRAL] 12
[AGENT][NEUTRAL] 664.
[CUSTOMER][POSITIVE] 4. OK, perfect. OK, the fax.
[AGENT][NEUTRAL] Alrighty and then do you have a fax number?
[CUSTOMER][NEUTRAL] Uh, what is that?
[AGENT][NEUTRAL] Um, oh, our fax number is uh.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII] 3.
[CUSTOMER][NEUTRAL] [PII] and then my fax number if you could please it's um [PII].
[AGENT][NEUTRAL] Yes. Yes.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, I'm going to read that back, make sure I heard that correctly. That was [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, and I would just put this to your attention, [PII].
[CUSTOMER][NEUTRAL] Oh yes please, and last name initial is [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm sorry, [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Oh, got you. OK, alright, I will get that sent to you now. Uh, should get it here in maybe 10-15 minutes depending on how busy your machine is. Um, did you have any other questions for me?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] No, so then I can go ahead and maybe submit this claim back under gastro and then for you the one under the center that will also has not been processed.
[AGENT][NEUTRAL] Yes
[AGENT][POSITIVE] That's perfectly fine.
[CUSTOMER][POSITIVE] With the explanation of benefits. OK, fantastic.
[AGENT][NEUTRAL] Yes, as long as we've got that primary EOB.
[CUSTOMER][POSITIVE] All right wonderful what is the reference number?
[AGENT][NEUTRAL] Reference number would just be my first name, last initial, and today's date and so my name is spelled K A R A, last initial is A.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK, and today's day, alright, thank you very much. I appreciate, uh, you know what, let me double check just in case I don't have another one for you before I hang up on you because that always happens. Give me just a second. Yeah, story of my life. Hold on, thank you, very kind. OK, let's see here.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Of course, yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] No, you're fine.
[CUSTOMER][NEUTRAL] OK, and I do see, OK, uh, let me know when you're, yeah, correct, yes ma'am.
[AGENT][NEUTRAL] OK, um, for a different member?
[AGENT][NEUTRAL] OK, give me just a moment, I'll let you know when I'm ready for that policy number.
[CUSTOMER][NEUTRAL] OK, I have the claim phone num uh uh and this one I do have the claim number.
[AGENT][NEUTRAL] OK, give me just a moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] All right. I am ready when you are.
[CUSTOMER][NEUTRAL] OK, policy ID is 02010880. Let me pull it because it seems like I'm missing the letters that you guys usually attached to.
[AGENT][NEUTRAL] That's OK. Um, honestly, that's all we really need is before that MLA, that's perfectly fine or ML7.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] 00 OK OK OK.
[AGENT][NEUTRAL] OK, um, what was the name and date of birth for this member?
[CUSTOMER][NEUTRAL] OK, I have [PII]. Let me pull up his date of birth.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Give me a second, of course I have [PII]. Hold on, let me try the subscriber ID.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, his date of birth is [PII].
[AGENT][POSITIVE] Perfect, thank you for verifying that. OK, and then you did have this claim number?
[CUSTOMER][POSITIVE] Yes, I have the first one. I do have 2 for him, yep.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, first claim number is 355-0280.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, look.
[AGENT][NEUTRAL] 578. OK, so this one is stating that the excuse me, maximum benefit payable for the date of service had been met.
[AGENT][NEUTRAL] So prior to on the same date of service we had already received a different claim, and that's where that benefit went.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so do they have a certain amount per day for a procedure or how does that work?
[AGENT][NEUTRAL] Typically, yes, let me double check this policy and we'll take a look. Yes, so this policy's outpatient benefit is on a per calendar day basis, so it is $500 max per calendar day.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] $500 max.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Per day basically OK alright and let's see here.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, because then I have for him 28-2024 uh that claim number is 355-0280.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, that's the one that we just looked at.
[CUSTOMER][NEUTRAL] I think I
[CUSTOMER][NEUTRAL] Oh, so sorry. hold up claim number claim number is 355-0274.
[AGENT][NEUTRAL] No, that's OK.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] 74 OK and did you need these EOBs, [PII], or do you have them?
[CUSTOMER][NEUTRAL] No, I, I have the UBs on this one I'm just calling, right, clarification, yes, thank you.
[AGENT][POSITIVE] OK OK perfect just wanted to make sure.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] Alright, this one is stating that it's not covered.
[AGENT][NEUTRAL] So it's not a covered outpatient service. So this one is stating that the covered services are uh hospital emergency room treatment, outpatient surgery in a hospital or an outpatient surgery center, and diagnostic testing in a hospital or in an MRI facility. So charges incurred in an independent lab are not covered under this policy.
[CUSTOMER][NEUTRAL] OK, so let's see here.
[CUSTOMER][NEUTRAL] OK, so if the lab work was done under the ambulatory center, then the place of service would have been different than that claim would have been reconsidered.
[AGENT][NEUTRAL] That's, yes, um, so this kind of, yeah, it's a bit confusing, uh, this policy is um more dependent on, yes, where the services were rendered.
[CUSTOMER][NEUTRAL] OK, alright, so.
[AGENT][NEUTRAL] Or the type of facility in which they were rendered.
[CUSTOMER][NEUTRAL] OK, so alright, so if it would have been done at the ambulatory facility, which was what they did, they did the procedure and then they did the pathology at the same time, then that would be cover expense.
[AGENT][NEUTRAL] Mm, yeah, the independent labs are not typically covered under these kinds of policies.
[CUSTOMER][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] OK, it just in case, does he have because this state of service was 2-12-2024, had his daily max been max on this patient by any chance?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Uh, let me check that date. Give me just a moment.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] What did you say the date was? I'm sorry.
[CUSTOMER][NEUTRAL] Yes, that's [PII].
[AGENT][NEUTRAL] [PII]. OK, let me take a look here.
[AGENT][NEUTRAL] No, um, so that was the only claim that we did receive for that date of service.
[CUSTOMER][NEUTRAL] OK, so we just need to change the place of service, OK, uh, and I would, we would just send basically a correct the claim, uh, not, not, notating the diff the different place of service and hopefully it could be reconsidered for payment.
[AGENT][NEUTRAL] You can, um, I think that would be considered more of an appeal, [PII], in which case I do believe it's out of that time frame um well let me actually see when this was processed.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Well yeah, take that back so I'll look at the date of service but since we received it somewhat recently, it does look like it's in that time frame um it is uh 180 days of the process date and this claim had processed [PII] of this year, so you should still be within that time frame yes, um, you could send all of that information. The only other thing that we would need additional is essentially a cover letter just explaining that it is an appeal.
[CUSTOMER][NEUTRAL] 100
[CUSTOMER][NEUTRAL] OK, so we have 180.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so a cover letter, uh, sending up that I'm sending a correct the claim, uh, uh, rectifying the place of service.
[AGENT][NEUTRAL] Right, right, um, but I, but again, I do believe that would be considered an appeal.
[CUSTOMER][NEUTRAL] OK, so, OK.
[CUSTOMER][NEUTRAL] OK, perfect. OK, thank you very much. I understand. And what would that reference number be for you? Do they have a different reference number? Well, I, it's the same, you're still, still your name I'm sorry, I just remember, OK.
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] This would be the same. My first name, last initial, yeah, and today's date that yes, that's correct. No, you're OK. Was there anything else I could help you with?
[CUSTOMER][POSITIVE] No, that'll be all thank you very much I appreciate the help alright.
[AGENT][POSITIVE] Alright, yeah, thanks for calling APL. Have a great rest of your day.
[CUSTOMER][NEUTRAL] Alright alright bye bye.
[AGENT][NEUTRAL] Bye bye.