AccountId: 011433970860
ContactId: 7c2c9034-5b42-4f15-850e-23de4f14771c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 976179 ms
Total Talk Time (AGENT): 181779 ms
Total Talk Time (CUSTOMER): 268572 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/06/7c2c9034-5b42-4f15-850e-23de4f14771c_20250606T16:14_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah. Hi, [PII]. My first name is [PII], and to my last, that would be [PII]. I'm calling from Coa Health Services ANC. I'm looking for claim status.
[AGENT][NEUTRAL] OK, I can help you with claim status list. Do you have a good callback number?
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Sure. Take note of my callback number. That's going to be [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the policy number for that patient?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Just bear with me.
[CUSTOMER][NEGATIVE] Uh, no.
[CUSTOMER][NEUTRAL] Hang on.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. That's 145295, I mean 294 7 W L Lima Bravo.
[AGENT][NEUTRAL] And patient name and date of birth?
[CUSTOMER][NEUTRAL] The patient's name is [PII] [PII].
[AGENT][NEUTRAL] And date of service and bill charges?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] There will be 1:30, 120, 24.
[CUSTOMER][NEUTRAL] And $215 even.
[AGENT][NEUTRAL] OK. Give me one moment.
[AGENT][NEUTRAL] OK, looks like we received this claim.
[AGENT][NEUTRAL] Yeah, that was on 4-9-2024, and that was processed 411-2024.
[AGENT][NEUTRAL] And type of service is not covered under the policy.
[CUSTOMER][NEUTRAL] So this is just a medical services. I believe all the medical.
[CUSTOMER][NEUTRAL] Policy will cover this medical services, right?
[CUSTOMER][NEUTRAL] Is there any specific reason that saying
[AGENT][NEUTRAL] Uh, this shows it was for kinesiology, speech, or occupational therapy. Is that correct?
[CUSTOMER][NEUTRAL] The
[AGENT][NEUTRAL] Based on the CVC code.
[CUSTOMER][NEUTRAL] Yeah, this is for physical occupation.
[AGENT][NEUTRAL] Yeah, so occupational therapy is not covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Occupational therapy, just bear with me.
[CUSTOMER][NEUTRAL] G. 0283.
[CUSTOMER][NEUTRAL] You know what, the CPT or the procedure 97,110 and 97,530, it's counts under physical therapy, not occupational.
[AGENT][NEUTRAL] Um, let me see if it was the place of service too. What was the place of service?
[CUSTOMER][NEUTRAL] Place of services office.
[CUSTOMER][NEUTRAL] Number 11.
[CUSTOMER][NEUTRAL] Because you can double-check the procedure code 97,530 and 97,110.
[CUSTOMER][NEUTRAL] Both are for therapeutic activities, not for speech or occupational.
[AGENT][NEUTRAL] OK, let me pull up the policy real quick.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, the place of service was.
[CUSTOMER][NEUTRAL] And could you spell out your name for me?
[AGENT][NEUTRAL] Uh yes, it's [PII]. It's [PII]
[AGENT][NEUTRAL] So it's the place of service. So because of the place of service office, it's not covered. It would have to be in a physical therapy facility.
[CUSTOMER][NEUTRAL] Physical therapy facility?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] So it can't be in the office, can't be placed to service 11.
[AGENT][NEGATIVE] That's not covered under this policy.
[CUSTOMER][NEUTRAL] So the policy is allowed to pay only the physical therapy services were taken in the physical therapy facility.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] This is the first time I'm hearing like this.
[CUSTOMER][NEUTRAL] Can you, can you please double-check one more time because the physical therapy services can take any other place if they have the kind of equipment, that kind of facilities. Since we have uh the kind of facilities and the kind of equipments in our office, so we done in the office. That's not an issue. I think the primary was actually processed and paid the claim.
[CUSTOMER][NEUTRAL] And I mean process the claim to which deductible.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] You can feel free to appeal the decision. Um, this is based on the policy and how it's written.
[CUSTOMER][NEUTRAL] So, since this is not covered as per the patient policy and this falls under a patient responsibility, can I go ahead and bill the patient?
[AGENT][NEUTRAL] We can't determine patient responsibility because we're a secondary policy, so we can't instruct on patient responsibility.
[AGENT][NEUTRAL] Because we're secondary.
[CUSTOMER][NEUTRAL] It seems like
[CUSTOMER][NEUTRAL] Not sure.
[CUSTOMER][NEGATIVE] This is a denial that I'm hearing first time, the place of service is not covered under the patient plan.
[CUSTOMER][NEUTRAL] So what place of services that we need to indicate? Do you mean facility in the sense, inpatient or outpatient?
[AGENT][NEUTRAL] Yes, outpatient facility.
[CUSTOMER][NEUTRAL] Or what facility that we need?
[CUSTOMER][NEUTRAL] Outpatient facility.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] That's what's covered under the policy.
[AGENT][NEUTRAL] Are you there?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Can I have the claim number?
[AGENT][NEUTRAL] 344-2740.
[CUSTOMER][NEUTRAL] And what is the timeless following limit for making an appeal?
[AGENT][NEUTRAL] Um, that is 180 days from the process date.
[CUSTOMER][NEUTRAL] 180 days from last process date which is 411.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] I believe that we have actually crossed the family farming limit. We have exceeded.
[CUSTOMER][NEUTRAL] Do you guys still accept the appeal if we submit?
[AGENT][NEGATIVE] It would be denied for outside of the time frame.
[CUSTOMER][NEUTRAL] And that's not a guarantee of payment.
[AGENT][NEUTRAL] Yeah, there's no guarantee of payment.
[CUSTOMER][NEUTRAL] Can I have the fax number?
[AGENT][NEUTRAL] Fax number [PII].
[CUSTOMER][NEUTRAL] Retention
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Attention to claims department or appeals department.
[AGENT][NEUTRAL] Uh, peels.
[CUSTOMER][NEUTRAL] And can I have the mailing address?
[AGENT][NEUTRAL] Mailing address is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]. OK, and.
[CUSTOMER][NEUTRAL] The claim number is 63,442,740.
[CUSTOMER][NEUTRAL] And shall we move on to the next date of service?
[AGENT][NEUTRAL] Is it for the same patient?
[CUSTOMER][POSITIVE] You're right.
[AGENT][NEUTRAL] OK. What is it?
[CUSTOMER][NEUTRAL] I have here the same number.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can I proceed, can I proceed with the claim number? That's 343-375-8.
[AGENT][NEUTRAL] OK, give me one moment.
[AGENT][NEUTRAL] This is on the same patient or a different one?
[CUSTOMER][POSITIVE] You're right.
[CUSTOMER][NEUTRAL] Same page.
[AGENT][NEUTRAL] Inpatient, OK.
[AGENT][NEGATIVE] Uh, this is denied for the same reason.
[CUSTOMER][NEUTRAL] And what is the patient plan name?
[AGENT][NEUTRAL] Patient plan name is.
[AGENT][NEUTRAL] Medlink, S as in Sam, F as in Frank, S as in Sam.
[CUSTOMER][NEUTRAL] SFS meddling SFS.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Supplement, right?
[AGENT][NEUTRAL] Secondary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] So if we like, we can submit the appeal, right?
[AGENT][POSITIVE] Yes, I mean, yeah, of course you can submit it. It's just like I said, it's 180 day window so but yes, I mean feel free to submit it.
[CUSTOMER][NEUTRAL] OK. And the next date of service would be [PII].
[CUSTOMER][NEUTRAL] And the claim number 3442749 for the same patient.
[AGENT][NEUTRAL] Uh, it's the same thing.
[AGENT][NEUTRAL] Oh it's 65 and then denied 67.
[CUSTOMER][NEUTRAL] 65.
[CUSTOMER][NEUTRAL] Received on 65 denied and 67.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Just bear with me. And can I have the received date and process it for the last time that we discussed?
[AGENT][NEGATIVE] 3:18 received, denied 320.
[CUSTOMER][NEUTRAL] 318 320, just bear with me.
[CUSTOMER][NEUTRAL] 313.
[CUSTOMER][NEUTRAL] 32.
[CUSTOMER][NEUTRAL] And for this one,
[AGENT][NEUTRAL] 656 7.
[CUSTOMER][NEUTRAL] Received in June, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 65
[CUSTOMER][NEUTRAL] There's 2 more data services for the same patient.
[CUSTOMER][NEUTRAL] Can I move on to the next date of service?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEGATIVE] I received [PII], process [PII] or denied [PII], same thing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Received them for one.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK, the next date of service would be.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Up until [PII].
[AGENT][NEUTRAL] Uh, that was.
[AGENT][NEGATIVE] I received 49, denied 411.
[CUSTOMER][NEUTRAL] Claim number?
[AGENT][NEUTRAL] 3442743
[CUSTOMER][NEUTRAL] You're like for the same reason?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much. Can I have the call reference?
[AGENT][NEUTRAL] It's my name, [PII] and today's date.
[CUSTOMER][NEUTRAL] Can I have your initial to lost?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thank you so much, [PII]. You have a great wonderful rest of your day. Happy weekend.
[AGENT][POSITIVE] Thanks.
[AGENT][POSITIVE] Thanks for calling APL. You too. Have a good weekend.