AccountId: 011433970860
ContactId: 6fe0a8bc-bbd2-4692-93e8-1eec7e91de9f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1190459 ms
Total Talk Time (AGENT): 277460 ms
Total Talk Time (CUSTOMER): 465137 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/30/6fe0a8bc-bbd2-4692-93e8-1eec7e91de9f_20250130T18:30_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL this is.
[CUSTOMER][NEUTRAL] Hi, this is
[AGENT][POSITIVE] Thank you for calling
[CUSTOMER][POSITIVE] Sorry, uh, sorry to interrupt, you can continue.
[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Hi, this is [PII]. I'm calling for the provider [PII]. Please be informed that this call is being recorded and monitored for quality and training purposes, and I'm here to check on a claim status.
[AGENT][NEUTRAL] Can I help you, [PII]. What's the policy number?
[CUSTOMER][NEUTRAL] Yeah, the number's policy number is 60801.
[AGENT][NEUTRAL] OK, that's the payer ID number.
[CUSTOMER][NEUTRAL] Sorry, I have the member ID 60801. Just a minute please. I'm looking on the ID card here.
[CUSTOMER][NEUTRAL] Just a minute please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, OK, sorry to, uh, sorry for the delay. Actually, I don't have the member ID here. Could you please check with the member's name and the date of birth?
[AGENT][NEUTRAL] Spell the patient's first and last name for me?
[CUSTOMER][NEUTRAL] Yeah, the patient's first name is [PII]. That is [PII], again, [PII], and last name is [PII]. That is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and what's a good phone number, [PII], in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, that is [PII] and it's a direct line.
[AGENT][NEUTRAL] OK, what were the first three digits? [PII]?
[CUSTOMER][POSITIVE] Yeah, that's correct. [PII].
[AGENT][NEUTRAL] OK. OK, one moment.
[CUSTOMER][NEUTRAL] Take your time. And could you please spell your name for my documentation purposes?
[AGENT][NEUTRAL] It's [PII]
[AGENT][NEUTRAL] And first initial of my last name is.
[CUSTOMER][NEUTRAL] That is [PII]. Am I correct?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the first initial of my last name, uh-huh, first initial of my last name is [PII]. One moment.
[CUSTOMER][POSITIVE] Thank you for that, [PII].
[CUSTOMER][POSITIVE] OK. Take your time.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And what's the patient's date of birth?
[CUSTOMER][NEUTRAL] Yeah, the patient's date of birth is on.
[CUSTOMER][NEUTRAL] Um, that's [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the policy number.
[AGENT][NEUTRAL] It's 240.
[AGENT][NEUTRAL] 892 5.
[AGENT][NEUTRAL] And you said that you're checking claim status?
[CUSTOMER][POSITIVE] OK, thank you for that.
[CUSTOMER][POSITIVE] Yeah, that's correct, [PII].
[AGENT][NEUTRAL] OK, what's the date of service in charge?
[CUSTOMER][NEUTRAL] Yeah, the day of service is on [PII], and the total charge amount is $609.89. That is 609.89 cents. You're welcome.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Mhm. Got it. Uh-huh.
[AGENT][NEUTRAL] And are there 2 procedure codes on that claim or 3 procedure codes?
[CUSTOMER][NEUTRAL] Just a minute please. I'm looking on the procedure codes here.
[CUSTOMER][NEUTRAL] That's 3 procedure codes on my claim.
[AGENT][NEUTRAL] OK, I think I have. All right, one moment.
[AGENT][NEUTRAL] And what are the procedure codes?
[CUSTOMER][NEUTRAL] Yeah, the procedure codes are.
[CUSTOMER][NEUTRAL] 97,110.
[CUSTOMER][NEUTRAL] With the modifier 97 and GP and the line two procedure codes are 97,530 with the modifier 97 and GP and the last procedure code is 97112 with a modified GP.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and the name of the provider's office?
[CUSTOMER][NEUTRAL] The provider's office name here is.
[CUSTOMER][NEUTRAL] Musculoskeletal Institute character sorry that's charter DBA Florida orthopedic Institute.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] So the claim was received [PII].
[AGENT][NEUTRAL] Process [PII].
[AGENT][NEUTRAL] And under this policy, when the claim is denied by the primary insurance, uh, the APL plan does not cover it.
[CUSTOMER][NEUTRAL] OK, so this is non-covered service as for the PF policy. Am I correct? As for the APL's policy.
[AGENT][NEUTRAL] Patients, patients policy.
[AGENT][POSITIVE] Mhm. Correct.
[CUSTOMER][POSITIVE] OK, patience. Thank you for that. Just a minute please. Let me open my tools here for you.
[CUSTOMER][NEUTRAL] Thank you for your patience, [PII]. May I know whether the CPT or the diagnosis is non-covered? Either both are not covered.
[AGENT][NEGATIVE] Yeah, all 3 charges were denied.
[AGENT][NEGATIVE] Because the primary denied the entire claim.
[CUSTOMER][NEUTRAL] OK. Uh,
[CUSTOMER][NEUTRAL] OK, just a moment please. Let me check the primary you'll be here.
[CUSTOMER][POSITIVE] Thank you for your patience, [PII]. I can see the primary has paid this claim for $90.
[CUSTOMER][NEUTRAL] And 11 cents they haven't denied the claim and they have paid each and every code on my claim. Could you please check that? Do you have a primary will be with you?
[AGENT][NEUTRAL] Uh, if you send it with the claim, we should have it. One moment.
[AGENT][NEUTRAL] And what's the date on the explanation that you have?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Today is on [PII].
[AGENT][NEUTRAL] That's the date that they processed it?
[CUSTOMER][NEUTRAL] Um, I don't know. That is pay date. That is [PII]. OK, take your time.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and the claim that I have shows a total charge of 700 as the bill amount?
[AGENT][NEUTRAL] You gave me a different total.
[CUSTOMER][NEUTRAL] Um, so just a minute please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh sorry, I have told the secondary build amount. I haven't provided you the right total bill amount. Sorry for that, uh, [PII], the total bill amount is $700. Sorry for that.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK, so the explanation of benefits that I have is dated. It's the pay date is [PII]. I'm showing in the deductible column all zeros, the co-insurance column all zeros, and the co-pay column all zeros.
[CUSTOMER][NEUTRAL] Yeah, but they have paid for the CPT 97,110 with a modified 97 and GP. They have paid $40.60 to 64 cents. For the second line they have paid $20.93. And the third CPT they have paid $28.54.
[AGENT][NEUTRAL] Yeah, it doesn't show paid. That's just the allowed amount that's in the allowed amount column on the ELB that we have. I don't show anything paid and it actually if you look at the remark codes on the claim.
[CUSTOMER][NEUTRAL] Could you see that with you?
[CUSTOMER][NEUTRAL] Yeah, I have the remark code CO45 and CO59 with me. Is that same with you?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, and so in the deductible column, do you see anything in the deductible column?
[CUSTOMER][NEUTRAL] No, they, they're all zeros.
[AGENT][NEUTRAL] OK, so this policy, the APL policy only reimburses the amounts in the deductible column, co-pay column, and co-insurance column, and I'm showing it's all zeros there.
[CUSTOMER][NEUTRAL] like.
[CUSTOMER][NEUTRAL] OK, so this is not covered the patient's policy. OK, thank you for that and uh
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Just a minute, please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's a bit please [PII]. I'm checking for the previous payment history here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you for your patience.
[CUSTOMER][NEUTRAL] OK, thanks for your patience, uh, [PII], could you please provide me the contact claims mailing address?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Exactly
[CUSTOMER][NEUTRAL] I know the
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII] City, [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] OK, thank you for that. Uh, may I know the current claims family filing limit?
[AGENT][NEUTRAL] For an appeal, it's 180 days from the date of denial.
[CUSTOMER][NEUTRAL] OK, for the current claims, may I know the
[CUSTOMER][NEUTRAL] Timely filing limit to submit a corrected claim.
[AGENT][NEUTRAL] Oh correct a claim. There's no timely filing limit.
[CUSTOMER][NEUTRAL] OK, so, uh, is the current claims mailing address and appeal mailing address the same? OK, thank you for that. Uh, could you please provide me the claim number, [PII]?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] 353-483-3
[CUSTOMER][NEUTRAL] Just to reconfirm that is 34, that is 35334833. Am I correct? Sorry, that is 3534833. Am I correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, thank you for that. uh, [PII], just a moment, please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Thank you for your patience. And could you please fax us a copy of UOB?
[AGENT][NEUTRAL] It was actually mailed when the claim was processed and now available to download on our online service center. Let me know when you're ready for that website.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, please.
[AGENT][POSITIVE] It's secured, S [PII]
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, remember I gave
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And you can search for the claim, uh, the ELB with the claim number provided.
[CUSTOMER][NEUTRAL] OK. Thank you for that, uh, [PII]. And could you please provide me the call reference number for this one. Before that, I do have one more claim and
[AGENT][NEUTRAL] My name
[AGENT][NEUTRAL] My name in today's date.
[CUSTOMER][NEUTRAL] OK, the call reference number will be, OK, thank you for that, [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] And I do have one more claim with me. Could you please assist me with that too, that is out of the same and the same patient, [PII].
[AGENT][NEUTRAL] The policy number?
[AGENT][NEUTRAL] It's
[AGENT][NEUTRAL] It's the same person?
[CUSTOMER][NEUTRAL] Yeah, same person.
[AGENT][NEUTRAL] The data service.
[CUSTOMER][NEUTRAL] Yeah, I'm looking for the date of service here that is [PII] sorry that is [PII].
[AGENT][NEUTRAL] The amount?
[CUSTOMER][NEUTRAL] The bill amount here is $700 even.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so this claim was received on [PII], processed [PII] or [PII], um, this claim, no payment was denied on this one it looks like the.
[CUSTOMER][NEUTRAL] Oh, could you
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um, primary insurance paid it in full.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, the primary insurance is paid it in full, am I correct?
[AGENT][NEUTRAL] Mhm. Mhm.
[CUSTOMER][NEUTRAL] OK, just a moment please. Uh, could you please provide me the process date one more time? Sorry for that. That is [PII].
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Receive [PII] process [PII].
[CUSTOMER][NEUTRAL] OK, thank you for that, [PII]. Just a moment please. Let me look out the primary will be here.
[AGENT][NEUTRAL] Anything else I can help with today, [PII]?
[CUSTOMER][NEUTRAL] Yeah, just a minute please. I'm looking on the primary of Betonia. Uh, I can see the primary hasn't paid the complete amount. We have billed the primary for $700 and they have paid only $69.79 dollars.
[AGENT][NEUTRAL] OK, on the explanation that we have [PII], it shows that they paid it in full, so you would need to reach out to the primary insurance regarding any difference that you may have.
[CUSTOMER][NEUTRAL] So we have this
[CUSTOMER][NEUTRAL] OK, OK, just a minute please let me document that here.
[CUSTOMER][NEUTRAL] OK, thank you for your patience, uh, [PII]. So the, uh, may I know the pin's mailing address is [PII]. Am I correct?
[AGENT][POSITIVE] It's the same one that I gave you earlier, yes, that is correct.
[CUSTOMER][NEUTRAL] OK, thank you for that. And the timely filing limit was 180 days from the day of denial. I'm I correct?
[AGENT][NEUTRAL] To file an appeal that is the timely filing limit.
[CUSTOMER][NEUTRAL] OK. OK, thank you for that. Uh, do we need to attach the primary UB with an nine?
[AGENT][NEUTRAL] Why are you appealing the claim?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Um, in, if in case for future reference.
[AGENT][NEUTRAL] You know, the only reason you would need to submit the ELB is if it shows differently is if it it and you don't have to appeal it if they went back and reprocessed it.
[CUSTOMER][NEUTRAL] that
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um, and you're saying that they paid something because on the other one you said they paid but they didn't. So is there anything in the deductible co-insurance co-pay column? Did they pay it in full?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um, I have a deductible in the deductible column, I have $160 in the CPT 97116 for the modified $97 and GP.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] What did the provider pay on that one?
[CUSTOMER][NEUTRAL] Uh, you mean how much they have? Are you are asking how much they have paid on this line?
[AGENT][NEUTRAL] The primary paid it in full. So what did they pay for that line item?
[CUSTOMER][NEUTRAL] OK, so just a moment please. Uh, I just need to know if in case for future references in other any any other claims, uh, do we need to attach the denied EOP with the appeal?
[AGENT][NEUTRAL] whatever documentation you feel is gonna help the appeal process. That's your choice?
[CUSTOMER][NEUTRAL] OK, so, um, and do we need to attach any specific form if in case we file an appeal?
[AGENT][NEUTRAL] you just submit your own appeal and attach any documentation as to why you're submitting the appeal. We do not have a form for you to complete.
[CUSTOMER][NEUTRAL] OK, there is no specific form. OK, thank you for that information, uh, [PII]. So, uh, do you have a claim number by any chance?
[AGENT][NEUTRAL] The claim number is
[AGENT][NEUTRAL] Give me one moment.
[CUSTOMER][POSITIVE] OK, take your time.
[AGENT][NEUTRAL] 352-561-5.
[CUSTOMER][NEUTRAL] OK, thank you for that, [PII]. So the call reference number will be your name and today's date. Am I correct?
[AGENT][NEUTRAL] That is correct. Anything else added?
[CUSTOMER][POSITIVE] No, that's all for today, [PII]. Thank you for your assistance today. Thank you for your patience and have a nice day. Bye-bye.
[AGENT][POSITIVE] Thanks for calling ATL. Have a good day.
[CUSTOMER][NEUTRAL] You too.