AccountId: 011433970860
ContactId: 717dc317-e40c-44df-8e6f-63799bdfe80b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 971669 ms
Total Talk Time (AGENT): 208650 ms
Total Talk Time (CUSTOMER): 267160 ms
Interruptions: 7
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/15/717dc317-e40c-44df-8e6f-63799bdfe80b_20250115T20:07_UTC.wav
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[AGENT][POSITIVE] Good Afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah. Hi, good afternoon. This is [PII] calling from provider office, check on the claim status. How are you doing today?
[AGENT][POSITIVE] I'm good, thank you. How about you, Miss [PII]?
[CUSTOMER][POSITIVE] Yeah, I'm doing good. Could you spell your name? I'm sorry.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure. My name is [PII].
[AGENT][NEUTRAL] And you're welcome. I need a callback number just in case we get disconnected.
[CUSTOMER][POSITIVE] OK. Thank you, sir.
[CUSTOMER][NEUTRAL] Yeah, yeah. It's gonna be [PII]. It's direct line, no extension.
[AGENT][NEUTRAL] OK, and may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] And the patient's policy number is 9800119, sorry, sorry, sorry. Uh, it's gonna be
[CUSTOMER][NEUTRAL] 02137652.
[AGENT][NEUTRAL] OK, thank you. One moment. Let's see.
[AGENT][NEUTRAL] What, what's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] It's [PII] and date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. And you say you need claim status today, correct?
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] Yeah. Actually,
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Actually, we have uh sent the corrected claim and appeal also. Have you received any corrected claim or appeal?
[AGENT][NEUTRAL] OK, what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] What is the
[CUSTOMER][NEUTRAL] Uh, date of service is [PII].
[CUSTOMER][NEUTRAL] And bill amount is $259.86.
[AGENT][NEUTRAL] OK, let me see if I can find this claim. Um, can I put you on a brief hold so I can check and see if we received any appeals or correct the claim on that one.
[CUSTOMER][POSITIVE] Alright thanks
[CUSTOMER][POSITIVE] Yeah, take your time. So.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding and being patient for me, Ms. [PII] OK, so I, I, I found two claims. Well, the original one and the one that we received, but it was just a regular claim and it was denied as a duplicate because the first one was denied uh correctly, which it was that office visits are not covered and um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Benefits are payable only if major medical insurance provide benefits.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK. And uh
[CUSTOMER][NEUTRAL] OK. I especially checking here.
[CUSTOMER][NEUTRAL] Uh, uh, our coding, internal coding team stated like, uh,
[CUSTOMER][NEUTRAL] The cod diagnosis code that uh like appropriate only as per supporting documentation.
[CUSTOMER][NEUTRAL] And they could it appropriately like that. Uh we have response here.
[AGENT][NEUTRAL] Hey Ms. [PII], that is not the denial we have on our end. The denial that is with us.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Is that office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] The offices are not covered by the policy.
[CUSTOMER][NEUTRAL] OK. Uh, so for this code 99213, right?
[AGENT][NEUTRAL] Yes, 99213 is denied office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] quite a
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh may I know when the claim was received?
[AGENT][NEUTRAL] The original one or the most recent one which it was denied as a duplicate because there's two of them.
[CUSTOMER][NEUTRAL] Initial. Yeah, most recent one.
[AGENT][NEUTRAL] The most recent one? OK, let me pull the information on that one moment.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] OK, so the most recent one was received on [PII], processed [PII].
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] Let's see 13 process [PII].
[CUSTOMER][NEUTRAL] [PII] processed. So this is, uh, so this claim was denied for denied due to office visits, right? Not covered by member's policy?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Correct, office visits are not covered by members policy.
[CUSTOMER][NEUTRAL] Correct, I.
[CUSTOMER][NEUTRAL] OK. Uh, sorry, I, can I have uh processed date again?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah [PII], right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So what we need to do, uh, uh, the next action.
[CUSTOMER][NEUTRAL] What's the next action we can do for this?
[AGENT][NEUTRAL] No, it's denied not covered by this policy, so it's up to the provider's discretion to know what he wants to do with the remaining of the claim benefit or amount.
[CUSTOMER][NEUTRAL] That's not.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Do we need to change any coding corrections or?
[AGENT][NEUTRAL] No, it's not about the coding, it's about the benefit not being paid by this policy. So it's not a payable benefit under this policy.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] So it's not a
[CUSTOMER][NEUTRAL] OK. Uh,
[CUSTOMER][NEUTRAL] What's the patient's plan?
[AGENT][NEUTRAL] This is a secondary supplemental plan to a major medical.
[CUSTOMER][NEUTRAL] Secondary
[AGENT][NEUTRAL] This is a secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] Uh, is it like HMO or PPO?
[AGENT][NEUTRAL] It's not an HMO or a PPO. This is a commercial secondary policy to the major medical.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And
[CUSTOMER][NEUTRAL] Is the patient active for this one, this policy?
[AGENT][NEUTRAL] OK, let me check the information. Um, this policy was effective [PII] and it is active at the moment and this is a secondary policy.
[CUSTOMER][NEUTRAL] This policy was effective [PII] and it is active at the moment. This is a policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Still active, right?
[AGENT][POSITIVE] Mhm, correct.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] What are the guidelines you are using?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, guidelines. What are the guidelines you are using?
[AGENT][NEUTRAL] OK, when you say guidelines, what do you mean? Why is it not covered under the policy?
[CUSTOMER][NEUTRAL] you
[CUSTOMER][NEUTRAL] Yeah. Uh, I'm asking, uh, what payer guidelines?
[CUSTOMER][NEUTRAL] Like, uh, uh, what the guidelines it was denied as non-covered charges.
[AGENT][NEUTRAL] It's per the policy. This policy again, this is not a major medical. This is a secondary supplemental plan to the major medical. The benefits on the policies indicate that there is no coverage for an office visit.
[CUSTOMER][NEUTRAL] On the policy indicated that there's no coverage for the president.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So, do we need to send any credit claim or appeal?
[CUSTOMER][NEUTRAL] What we need to do.
[AGENT][NEUTRAL] It's up to the provider's discretion again and it's not payable on the patient's plan.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, just give me a moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, can I have the claim number?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure. The claim number is um for the original one or the duplicate one.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The claim number is um.
[CUSTOMER][NEUTRAL] It's the the duplicate one.
[AGENT][NEUTRAL] The duplicate. OK. And that's gonna be 353-085-0.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 530,850. OK, and can I have the conference number?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in the name.
[CUSTOMER][NEUTRAL] O.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you, sir. Thank you for your, thank you for your assistance and thank, thanks for the information you have given.
[AGENT][NEUTRAL] Mm
[AGENT][POSITIVE] No problem. Thank you for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Thank you for
[CUSTOMER][POSITIVE] Yeah have a great day. Take care. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Oh.