AccountId: 011433970860
ContactId: 79c5ad44-becb-4be4-80b8-4643fda17e6b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 658500 ms
Total Talk Time (AGENT): 256925 ms
Total Talk Time (CUSTOMER): 157871 ms
Interruptions: 0
Overall Sentiment: AGENT=1.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/79c5ad44-becb-4be4-80b8-4643fda17e6b_20250123T17:57_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling from the provider's office to check on the claim status.
[AGENT][POSITIVE] OK, yeah, I'd love to help you with claim status today and do you mind if you spell your name for me please?
[CUSTOMER][NEUTRAL] Yeah. It's [PII], and the initial of the last name was [PII]
[AGENT][POSITIVE] Thank you [PII], I appreciate that and what's a good call back number I can get from you as well?
[CUSTOMER][NEUTRAL] The callback number is [PII].
[AGENT][NEUTRAL] Thank you, and the policy number?
[CUSTOMER][NEUTRAL] Uh, yes, the policy number is 0251237777.
[AGENT][POSITIVE] Thank you. Give me a moment to get that pulled up for you.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] Perfect. And would you be able to verify for me your insured's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes. The
[CUSTOMER][NEUTRAL] Patient's full name is [PII].
[CUSTOMER][NEUTRAL] And the date of birth is?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. I do see her right here and did you have a claim number on file you want to look at or the date of service to search for it?
[CUSTOMER][NEUTRAL] Date of service.
[AGENT][NEUTRAL] All right, and
[AGENT][POSITIVE] Perfect what is the date of service?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] And the bills out?
[CUSTOMER][NEUTRAL] It's $1,057 even.
[AGENT][POSITIVE] Perfect.
[AGENT][NEUTRAL] And what was the name of the facility on file?
[CUSTOMER][NEUTRAL] The facility, it's Community Medical Associates.
[AGENT][NEUTRAL] OK, perfect. You sure this is your claim, my friend. I show.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] I show your claim here. It looks like we received it [PII]. It looks like we processed it [PII].
[AGENT][NEUTRAL] I have your claim number listed as 355006.
[AGENT][NEUTRAL] And I do show that that claim was denied. I have the reason stating um.
[AGENT][NEUTRAL] I have a couple different denial codes here, um.
[AGENT][NEUTRAL] So it says that the benefit maximum for the state of service has been met.
[AGENT][NEUTRAL] And it says.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] This policy does not provide benefits for vaccines and immunizations or the administration of injections.
[AGENT][NEUTRAL] And those are the two different denial codes I have.
[CUSTOMER][NEUTRAL] Uh, one is the maximum benefits maximum benefits exhausted, and another one was non-cloud services. Am I right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] And that non-covered service was for code 90739 and 90471 and then that maximum uh benefit exhausted was for 99214.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. May I know the
[CUSTOMER][NEUTRAL] So, um, the non-core services are as per the patient's plan or as per the provider's contract.
[AGENT][NEUTRAL] As per the patient's plan.
[CUSTOMER][NEUTRAL] May I know what are exactly non-covered and why is it non-covered?
[AGENT][NEUTRAL] Yeah, so it says that the policy does not cover, um, it says this policy does not provide benefits for vaccines and immunizations or the administration of injections.
[CUSTOMER][NEUTRAL] OK. In that case, can you please tell me the allowed limit of the
[CUSTOMER][NEUTRAL] 4 99214.
[AGENT][NEUTRAL] The limit of that code, yeah, I can look at that for you. um I do wanna let you know any benefit information I give you over the phone today is always just a verification of coverage and not a guarantee of payment.
[AGENT][NEUTRAL] Um, it looks like your insured has a benefit of, um, it's their outpatient accident and sickness in the physician's office. They have that benefit they can utilize up to 4 times a year and up to $50 per visit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] $50 per week.
[CUSTOMER][NEUTRAL] So, is this,
[CUSTOMER][NEUTRAL] Is the benefits exhausted as for the units or the dollar value?
[AGENT][NEUTRAL] It was the unit, so they've used, they've met all four of their visits in a year that they were able to hit.
[CUSTOMER][NEUTRAL] OK. Just give me a moment, please.
[AGENT][NEUTRAL] You're fine.
[CUSTOMER][POSITIVE] Uh, thank you for staying online.
[AGENT][POSITIVE] No worries.
[CUSTOMER][NEUTRAL] Uh, as for review, I have seen the CPT 99214 twice only in this year.
[AGENT][NEUTRAL] Yeah, so they could have been, it could have been used with other um.
[AGENT][NEUTRAL] Other physicians' offices.
[CUSTOMER][NEUTRAL] So, OK.
[CUSTOMER][NEUTRAL] Is it a, so this is also a PR denial, right? Patient's responsibility.
[AGENT][NEUTRAL] Because we're their supplemental policy, we're not allowed to determine patient responsibility.
[CUSTOMER][NEUTRAL] Um, can you please tell me, can we bill the patient for this denial?
[AGENT][NEUTRAL] So APL is a limited supplemental policy we're not allowed to determine patient responsibility that's gonna be up to your provider's office.
[CUSTOMER][NEUTRAL] Uh, OK.
[CUSTOMER][NEUTRAL] Sorry to ask now. Can you please spell your name?
[AGENT][NEUTRAL] Yes, yeah, you betcha. My name is [PII] and then the first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK, [PII]. I don't have the explanation of benefits here. Can you please send me a
[AGENT][POSITIVE] Oh, I can help you with that.
[CUSTOMER][NEUTRAL] Yeah. Can you please send me an UOB copy?
[AGENT][POSITIVE] Absolutely let me get that pulled up for you real quick and I can fax it to you no worries. I do wanna let you know in case you don't know um but we have a web portal where you can get your explanation of benefits, um, if you're interested in getting the website um.
[AGENT][NEUTRAL] But we do make those available to providers online if you ever want to use that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the website if you'd like it is [PII].
[AGENT][NEUTRAL] And I'm just waiting for that fax box to load on my side.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] Uh, sorry, I didn't get you.
[AGENT][NEUTRAL] And do you want that made attention to yourself, [PII]?
[CUSTOMER][NEUTRAL] Sorry, I didn't get you Ali. Can you please repeat?
[AGENT][NEUTRAL] Oh yes, um, would you like me to make that fax attention to you?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And what is that fax number, friend?
[CUSTOMER][NEUTRAL] The fax number is
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] 22
[CUSTOMER][NEUTRAL] 899
[CUSTOMER][NEUTRAL] 254
[CUSTOMER][NEUTRAL] With the attention of [PII], my name.
[AGENT][NEUTRAL] Perfect, [PII], and I have that going to [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Perfect. I'm hitting send on that right now. It shouldn't be too much longer. Uh, typically takes 5 to 15 minutes to come through. And was there anything else I can help you with?
[CUSTOMER][NEUTRAL] No, [PII]. That's no further.
[AGENT][POSITIVE] Perfect. Well, thank you so much for calling us at APL and I hope you have a fabulous day.
[CUSTOMER][POSITIVE] Yeah, have a good day. Bye.
[AGENT][NEUTRAL] You too bye bye.