AccountId: 011433970860
ContactId: 7b6d2b2c-5f35-43a4-9c65-395b665cf503
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 846530 ms
Total Talk Time (AGENT): 412306 ms
Total Talk Time (CUSTOMER): 238447 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/12/7b6d2b2c-5f35-43a4-9c65-395b665cf503_20250212T14:17_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII] speaking. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII]. How are you?
[AGENT][POSITIVE] Doing well [PII] thank you how are you?
[CUSTOMER][NEUTRAL] Good, can you look at a claim with me?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Um, the policy number is 2039877.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For part two?
[AGENT][NEUTRAL] Just give me one.
[AGENT][NEUTRAL] Part two?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I have the provider on the line. They submitted. They say a reconsideration, but we did not it as a duplicate under claim 3544.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 209.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And I'm gonna pull that claim image. Did you need me to speak with them or?
[CUSTOMER][NEUTRAL] Yeah, it needs to be reprocessed.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] There were they split the $500 into two lines and so one they applied $250 deductible, the other they applied 14807 deductible on the ELB.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And was it, let me take a look at.
[AGENT][NEUTRAL] Yeah, because it does show.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] I'm looking at the document now from when it was processed the first time it looks like that's where.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Did you wanna go ahead and transfer them to me or how do you wanna do this?
[AGENT][NEUTRAL] Are you still there [PII]?
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] I need it. I was coughing, yeah, so yes, I wanna go ahead and transfer the call so that it'll need to be reprocessed.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] Alrighty, his name is [PII].
[AGENT][NEUTRAL] OK, and that's says call back that's listed?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] It is 800.
[CUSTOMER][NEUTRAL] 986.
[CUSTOMER][NEUTRAL] 5641
[CUSTOMER][NEUTRAL] Extension [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Alright, I'll take it from here and of course everything's been verified, right?
[CUSTOMER][POSITIVE] All righty.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] Yes it has. Here it comes. Uh thanks.
[AGENT][POSITIVE] Great. OK. Thank you so much. All right.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hi, my name is [PII]. I'm in the claims department. So I'm taking a look at that claim uh information for uh Ms. [PII]. So just bear with me for one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I'm pulling up the documents from when the claim was first uh billed so just bear with me for one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so it looks like when the claim, uh, first, the first submission it showed the patient's responsibility of 398-07, is that right?
[CUSTOMER][NEUTRAL] Mhm yes.
[AGENT][NEUTRAL] OK. All right.
[AGENT][NEUTRAL] OK, just bear with me for one moment while I and uh.
[AGENT][NEUTRAL] Continue to review this.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so what it appears here to me is that the um when the the first submission it only showed a $250 patient responsibility so we made that benefit payment of the $250 for that claim. Now, um, just one moment I'm gonna pull up the other one and just verify.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It shows something different.
[AGENT][NEUTRAL] OK, so, um, it does still show that 250, so, um, that's why it was denied on the second claim submission, the 354-4209 claim.
[CUSTOMER][NEUTRAL] What
[AGENT][NEUTRAL] Um, that
[AGENT][NEUTRAL] Uh, explanation of benefits shows the total remember responsibility to be $250.
[AGENT][NEUTRAL] So this policy will pay uh the co-insurance and or deductible amount for services left from that primary insured uh uh uh primary, I'm sorry, that primary insurance, um, payment. So when that, um, member responsibility, it says $250 that's the maximum that we can pay on that claim based on the primary insurance, um, explanation of benefits.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] But did, did you get what I'm saying that the member responsibility in this claim, it is $398.07 not the $250.
[AGENT][NEUTRAL] However, the explanation of benefits does not, uh, it does not show that amount. Just bear with me for one moment.
[AGENT][NEUTRAL] Just bear with me.
[CUSTOMER][NEUTRAL] Actually we already we also uh submitted an appeal on this one on [PII] uh with the primary UB also we attached the primary UB also on this one.
[AGENT][NEUTRAL] And that was on what date? My apologies.
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] And it was an appeal?
[CUSTOMER][NEUTRAL] Yes, have you faxed it?
[AGENT][NEUTRAL] Or a claim or a claim consideration.
[CUSTOMER][NEUTRAL] Like we just uh send in uh appeal letter like uh appeal letter with the primary you'll be having a detailed information about that that the member responsibility is $398.07 not the $250.
[AGENT][NEUTRAL] OK, well, it, I do see where that came through as a um submission on [PII] however it's not marked as an appeal if you're an appeal and it it has to be marked as an appeal and um it would need of course the supporting documentations which you did provide. So that's why the claim was denied as a duplicate because it wasn't marked as an appeal so it was basically like we saw the same claim information that was uh.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Uh, submitted previously. Now, um, just give me one moment. I'm still searching under this. I'm, I'm, I'm looking for that amount under the other, uh, under the other submission, so bear with me for just a moment.
[AGENT][NEUTRAL] Because I see it looks like it was on two different lines and I'm not sure why, um, and that's probably how come it's overlooked.
[CUSTOMER][NEUTRAL] uh, uh, I already explained to the previous rep as that because the CPT we used 50 modifier for the bilateral services. That's why the United Healthcare, they split the amount into $250 and $250 because the total amount of that CPT is $500. So that's why they split that uh amount in two line items. One is for $250 and another one is $250.
[AGENT][NEUTRAL] Yeah, I see that. Mhm.
[CUSTOMER][NEUTRAL] The upper line, the first line is $250. Whole amount is, uh, uh, went to the patient responsibility in which $210 is deductible and other amount is other, uh, $40. It is a copay and the next line item shows $148.07 as a deductible.
[AGENT][NEUTRAL] Yes, I see that.
[AGENT][NEUTRAL] OK, so like I said it wasn't marked as an appeal, so my apologies for that. However, if you're going just for future reference if you're gonna appeal a denial, it needs to be marked as an appeal and then like I said, include that information that would.
[CUSTOMER][NEUTRAL] Yeah, so, uh, it will be totally, uh.
[AGENT][NEUTRAL] Uh, render a different claim decision, so I see what you're talking about with the, uh, split line. So what I'm gonna do at this point for you, [PII], is I have to send an internal request to have the adjuster review this explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, now what will happen is, uh, once that is reviewed and the claim needs to be reprocessed, that will be done, um, by that representative. Now the number I was provided for a call back for you can, um, can I just verify I have the correct callback number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, I have, uh, the caller callback number it is [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] With the extension [PII].
[AGENT][NEUTRAL] OK great alright so what's gonna happen now, uh, [PII] is I'm gonna do an internal request to have the claim reviewed if you can allow us um 3 to 5 business days for that review to take place and the claim, um, now I will tell you this, um, again, my name is [PII]
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] My last initial is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, if for some reason the claim cannot be reprocessed and I need additional information, I will contact you. Otherwise, like I said, if you could allow us 3 to 5 days to have the claim, uh, for the turnaround time for the claim review, and if it, uh, will reprocess a new claim number will be generated and an explanation of benefits will accompany that.
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Did you have any other questions, [PII]?
[CUSTOMER][NEUTRAL] Uh, and
[CUSTOMER][NEUTRAL] Uh, yeah, just help me with the call reference number on this one.
[AGENT][NEUTRAL] Sure, so the call reference number you again would use my name R O X Y L for [PII], and today's date is your call reference number and I will also document this in the uh patient's file as well.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Mhm OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right. Thank you so much, [PII]. I really appreciate your help. Have a great day. Bye for now.
[AGENT][POSITIVE] You too [PII] thank you oh yeah.
[CUSTOMER][NEUTRAL] And also, uh, you're asking about, uh, you're telling about the appeal so there is any kind of, uh, you have any document that uh for that appeal form.
[AGENT][NEUTRAL] Um, no, you would just write it like I said, and you would want to address it as an appeal. So once uh a claim denial and you have a decision on a claim and you want to appeal that decision, you would mark the the information as an appeal include any supporting documentation which you kind of did on this um claim reconsideration, but again that's how it was viewed as like a claim reconsideration. I'm not certain, uh.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] In this one also actually we submitted as an appeal only like uh we included the letter also in this one but uh I don't know why it is not showing you guys as an appeal.
[CUSTOMER][NEUTRAL] Like I what information need to added like we already submitted that we already consider that uh will be also on that one that uh what is exactly we required on this claim. So what more things like we can add for the future.
[AGENT][NEUTRAL] Well, again, it
[AGENT][NEUTRAL] You would just say, uh, OK, now, uh, excuse me, I'm sorry, my apologies. I do see, uh, I do see that attached documentation and I'm not certain um what happened with this, but you are correct. I do see that it was marked um on the additional documents that were submitted as an appeal, um.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] So I will definitely make a note of that as well.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Mhm, OK, thanks so much [PII]. I really appreciate your help. Have a great day. Stay safe and bye for now.
[AGENT][POSITIVE] You too [PII] thank you so much for calling American APL. Hope you have a great day as well.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Bye.