AccountId: 011433970860
ContactId: 84246843-bb13-48f8-ad04-1c84f6b480bf
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 3545679 ms
Total Talk Time (AGENT): 1249141 ms
Total Talk Time (CUSTOMER): 786195 ms
Interruptions: 8
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/06/84246843-bb13-48f8-ad04-1c84f6b480bf_20250106T18:09_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] from Tennessee Interventional Imaging Associate provider office, and I'm checking on claim denial. Could you please help me?
[AGENT][POSITIVE] Yeah, I'd love to help you with that today and do you mind, [PII], if I get a good call back number for you real quick?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And what is that member's policy number?
[CUSTOMER][NEUTRAL] Member's policy number is
[CUSTOMER][NEUTRAL] 023 06089
[AGENT][NEUTRAL] Let me get that pulled up real quick.
[AGENT][NEUTRAL] And could you verify your patient's first and last name and date of birth, please?
[CUSTOMER][NEUTRAL] Member's first and last name is [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Wonderful. And do you have that claim number handy?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What is the date of service for the claim?
[CUSTOMER][NEUTRAL] Just a moment, let me check.
[CUSTOMER][NEUTRAL] Just a moment. I think I have the claim number.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] The claim number is.
[CUSTOMER][NEUTRAL] No, ma'am. I don't have the claim number. No claim number 353.
[AGENT][NEUTRAL] No worries. Do you have that data.
[AGENT][NEUTRAL] 358
[CUSTOMER][NEUTRAL] Yeah, I got it. I apologize. 353-923-3.
[AGENT][POSITIVE] All righty.
[AGENT][NEUTRAL] All right, so it looks like
[AGENT][NEUTRAL] The claim was denied because the calendar year maximum on diagnostic services has been met.
[CUSTOMER][NEUTRAL] Diagnostic service or diagnosis?
[AGENT][NEUTRAL] So it looks
[AGENT][NEUTRAL] So your patient only has
[AGENT][NEUTRAL] Two benefits for diagnostics. The first one is diagnostic imaging, um, and they have a $100 benefit they can use once per calendar year. If they were to receive a follow-up diagnostic test, it's only $25.
[CUSTOMER][NEUTRAL] Ma'am, I request you could you please go for documentation.
[AGENT][POSITIVE] I'm so sorry.
[CUSTOMER][NEUTRAL] I request you to, could you please go slow if you don't mind like for documentation.
[AGENT][NEUTRAL] Oh, like, so you can know, no worries. OK. Um, so they have a d
[CUSTOMER][NEUTRAL] As you stated, patient has only 2 diagnostic benefits.
[AGENT][NEUTRAL] Yep, one is for an initial diagnostic testing, and they can receive a $100 benefit once per calendar year.
[CUSTOMER][NEUTRAL] Just a moment. In one is initial diagnostic?
[AGENT][NEUTRAL] And then they have
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Testing.
[CUSTOMER][NEUTRAL] One is initial diagnostic testing for.
[CUSTOMER][NEUTRAL] $1000.
[AGENT][NEUTRAL] $100 once per calendar year.
[CUSTOMER][NEUTRAL] Once per calendar year, OK. And then?
[AGENT][NEUTRAL] And then there's a follow-up diagnostic testing listed for $25 once per calendar year.
[CUSTOMER][NEUTRAL] Following follow-up diagnostics testing.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For $25 once in the year.
[AGENT][POSITIVE] Yep, um, I do want.
[CUSTOMER][NEUTRAL] Member has only these two benefits.
[AGENT][NEUTRAL] Yes, those are the only two benefits for diagnostics on their policy. Um, so it looks like their diagnostic benefits. Those are the only two. It looks like those have been exhausted already.
[CUSTOMER][NEUTRAL] Sorry?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So member has only 22 benefits that is uh diagnostic testing only.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And ma'am, I don't have any CT scan, X-rays, nothing?
[AGENT][NEUTRAL] No, that's, uh, this is a very limited hospital indemnity policy. They, that's the only benefit for diagnostics.
[CUSTOMER][NEUTRAL] Limited
[AGENT][NEUTRAL] Yeah, it's a limited hospital indemnity policy.
[CUSTOMER][NEUTRAL] Limited hospital indemnity policy.
[AGENT][NEUTRAL] You betcha. And I do want to let you know just because I talked about their diagnostic testing benefits that any benefits we give over the phone is always a verification of coverage and never a guarantee of payment.
[CUSTOMER][NEUTRAL] OK, so the member has already exhausted the $100 per calendar year and also the $25 per calendar year.
[AGENT][NEUTRAL] It just states that their diagnostic benefits have been exhausted, so it sounds like, yes, both of them.
[CUSTOMER][NEUTRAL] Diagnostic benefit have been exhausted.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, so all the claims might have been denied for the same reason, right?
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEGATIVE] But few of them it is showing as non-covered.
[CUSTOMER][NEUTRAL] Benefits. Could you please check this claim number 353-9249?
[AGENT][NEUTRAL] Oh, OK, um, let me look, you said 9429?
[CUSTOMER][NEUTRAL] 92493539249.
[AGENT][NEUTRAL] 249.
[AGENT][NEUTRAL] All right, so then this one I have.
[AGENT][NEUTRAL] Um, they were all denied for the same reason. It says the medical test for the state of service is not a covered diagnostic. Therefore, no benefits are payable for this claim. Cover tests include MRI, CAT scan, thyroid uptake test, CT scan, PET scan, angiogram, barium enema, and lower GI series, um, myelogram, I'm sorry, I cannot pronounce that, nuclear stress test, ardiogram, barium swallow, upper GI series, sleep study, and uh TEE.
[CUSTOMER][NEGATIVE] So basically, this is uh also uh denied us benefit have been exhausted, diagnostic benefits have been exhausted, right?
[AGENT][NEGATIVE] So this one is saying that whatever procedure he had done wasn't one of these listed procedures and therefore it's not covered.
[CUSTOMER][NEUTRAL] So why is not good, ma'am. So both, both the things are the same or different?
[AGENT][NEUTRAL] Those are different denial codes. I guess I only was looking at the one claim because that's all you'd given me. So that first claim was all denied for the same denial reason. This one's denied for a different denial reason.
[CUSTOMER][NEUTRAL] Just a moment then, ma'am. As you stated, all have been denied for the same reason I got confused.
[AGENT][NEUTRAL] Oh, that's OK. You'd only given me the one claim number to look at, so I didn't know that there was another claim with different denial codes at that time.
[CUSTOMER][NEUTRAL] OK, give me just a second.
[CUSTOMER][NEUTRAL] OK, could you please check for the.
[CUSTOMER][NEUTRAL] Proceed a claim number.
[CUSTOMER][NEUTRAL] 353-846-2
[AGENT][NEUTRAL] One second.
[AGENT][NEUTRAL] 353-846-2
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, I see that claim here. Um, it looks like the denial code on this one, just states our records indicate that premium for this service date was not received. Therefore, benefits are not payable. If premium is being paid through COBR, please contact us at [PII], option number 2.
[CUSTOMER][NEUTRAL] Sorry, what is, could you please go slow, ma'am?
[AGENT][NEUTRAL] Um, our records indicate that premium for this service date was not received. Therefore, benefits are not payable. If premium is being paid through COR, please contact us at
[AGENT][NEUTRAL] [PII], option 2.
[CUSTOMER][NEGATIVE] OK, so premium for this service was not received. Therefore benefits are not payable and uh.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, give me just a moment.
[CUSTOMER][NEUTRAL] 72
[CUSTOMER][NEUTRAL] OK. Can we go ahead with the next claim number?
[AGENT][POSITIVE] Uh, yes, absolutely. What is that next claim number for you?
[CUSTOMER][NEUTRAL] 353-844-3.
[AGENT][NEUTRAL] All right, this one has the same as the last one is that our records indicate premium for the date of service was not received and therefore benefits are not payable.
[CUSTOMER][NEGATIVE] Premium for this service was not received, therefore benefits are not payable.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][POSITIVE] No worries.
[CUSTOMER][NEUTRAL] Then can you please check for the claim number 353-9226?
[AGENT][NEUTRAL] 353 90, I'm so sorry.
[CUSTOMER][NEUTRAL] 353-922-6
[AGENT][POSITIVE] Thank you for repeating that. I really appreciate it.
[CUSTOMER][POSITIVE] Not a problem.
[AGENT][NEUTRAL] All right, it looks like all of that one,
[AGENT][NEUTRAL] has is the medical test for the state of service is not a covered diagnostic test. There are no, therefore, no benefits are payable for this claim. Cover tests include, and then it lists all those cover tests again.
[CUSTOMER][NEUTRAL] But ma'am, this is the same claim which has been uh same claim then how it is initially denied for that reason and later on denied for this reason.
[AGENT][NEUTRAL] I'm so sorry. It's the same claim as what?
[CUSTOMER][NEUTRAL] I'm asking you, initially what you stated to me that the denial was premium for the service was not received. Therefore, benefits are not payable, right?
[AGENT][NEUTRAL] You've given me 12345 different claim numbers. I haven't looked at this claim yet before.
[CUSTOMER][NEUTRAL] Not that same numbers.
[CUSTOMER][NEUTRAL] No, I'm asking you just about this claim, which is initially I have provided you 353-844-3, right?
[AGENT][NEUTRAL] Yep.
[CUSTOMER][NEGATIVE] And you stated for that, the denial is premium for the services not received. Therefore, benefits are not payable. And again, I have provided you while the claim was submitted twice, that claim number was 3539226 for the same claim. And you are stating this is denied as non-covered something you are stating, right?
[CUSTOMER][NEUTRAL] Non-go procedure or non go diagnostic.
[AGENT][NEUTRAL] Yes, so.
[CUSTOMER][NEUTRAL] Then how is it possible that you need to be denying for the premium and then later non covered?
[AGENT][NEUTRAL] So, claim number 353-8443.
[AGENT][NEUTRAL] The denial codes on it state.
[AGENT][NEGATIVE] That the premium was not received and then.
[AGENT][NEUTRAL] The next one.
[AGENT][NEUTRAL] 353-922-6. I'm typing that in the wrong spot.
[AGENT][NEUTRAL] Um, I'm not really sure honestly. I can submit a request for an examiner to give you a call back and explain it further. All I can do is just read you the remarks off the EOB.
[CUSTOMER][NEUTRAL] No, but that is not my concern, ma'am. My concern is initially, they stated that this claim is denied that ending with 8443 was not premium received. And later on, while I have provided you the claim number which was submitted twice, this claim, and that was denied for something non-covered diagnostic. How is that possible?
[AGENT][NEUTRAL] I think when there's more than one denial reason, they can pick whichever denial reason they want, so you resubmitted the claim and it was denied. um, but I'm not sure. I'm not an examiner. I don't process claims. So again, if you need further information on why claims were denied the way they were, I would have to submit a request for an examiner to give you a call back.
[CUSTOMER][NEUTRAL] So like
[CUSTOMER][NEUTRAL] Not a callback. You can send for review, right? Like how there would be two denials on one claim.
[AGENT][NEUTRAL] Well, they're two separate claims.
[CUSTOMER][NEUTRAL] Like if the claim is financially premium.
[CUSTOMER][NEUTRAL] Not two separate, and both are the same.
[AGENT][NEUTRAL] Well they have separate claim numbers?
[CUSTOMER][NEUTRAL] That is the reason I'm seeing you, ma'am. I have two I have provided you two separate claim numbers for the same claim.
[AGENT][NEUTRAL] OK. So what I can do is I can submit for an examiner to give you a call back and explain their denial process.
[CUSTOMER][NEUTRAL] That is my question.
[CUSTOMER][NEUTRAL] No, but not that.
[CUSTOMER][NEUTRAL] On that, again, we have to keep the pending claim, pending the claim on our backlogs. Then you can send an inquiry or you can do a, a request for review.
[AGENT][NEUTRAL] Yeah, the they will review it and then they'll call you back and let you know.
[CUSTOMER][NEUTRAL] So you're, you're sending for review?
[AGENT][NEUTRAL] Yeah, I'm going to have an examiner review the two claims and give you a call back and explain how it was denied.
[CUSTOMER][NEUTRAL] Now, the initial claim was denied for premium.
[AGENT][NEUTRAL] Yeah, so I don't process claims, sir, so you have to understand that like there's things that I can't answer for you.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And I understand you want answers. I can have an examiner review the two claims and give you a call back and give you the answers you're looking for.
[CUSTOMER][NEUTRAL] I have several things like that.
[CUSTOMER][NEUTRAL] I have several claims like that.
[AGENT][NEUTRAL] OK, again though, I don't process the claims, so there's not much I can tell you beyond what is stated on the explanation of benefits. All I can do is have somebody research it and give you a call back.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] But ma'am, my is not that.
[CUSTOMER][NEUTRAL] Yes, I understood totally that you can, uh, you're not the examiner, you're not the tester of the claim. You're not the processor of the claim. I totally that. But my question is like,
[CUSTOMER][NEUTRAL] Who handles this claim. And uh we have several claims.
[CUSTOMER][NEGATIVE] Like there are 2 denials on each claim.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Who handles this claim so that I can directly reach over to them.
[AGENT][NEUTRAL] I can't give you anybody's direct information, but what I can do is I can get somebody who handles this claim to review it and give you a call back.
[CUSTOMER][NEUTRAL] So for all the claims?
[AGENT][NEUTRAL] Yeah, if you have sets of claim numbers you want me to look at if they're all for the same patient, I can go ahead and list them if they're for a separate um individuals then I would have to put in separate requests for each separate individual.
[CUSTOMER][NEUTRAL] Yes, give me just a moment so that I will just provide you the
[CUSTOMER][NEUTRAL] I will provide you the bill date of service and the bill amount, OK? Will that be OK?
[AGENT][NEUTRAL] Um, I'll actually, I'm gonna need the individual claim numbers, so you're gonna have to hang tight with me because I'm gonna have to look them up one by one.
[CUSTOMER][NEUTRAL] But, ma'am, as I'm stating you there.
[CUSTOMER][NEUTRAL] Yes, ma'am. As I'm stating you, there are several claims. So I can't provide you all, for all the claims, there are 2 claims.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] You got my point because there are 2 claims for all the claims.
[CUSTOMER][NEUTRAL] So it will be hectic for me.
[CUSTOMER][NEUTRAL] So that is the reason I'm providing you the date of service and the bill amount.
[AGENT][NEUTRAL] OK, so what I'm telling you though is you're gonna have to hang out with me while I look up each date of service, each build out, and then both claim numbers for each one and then submit the requests, so.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I like, I understand it's like a lot of information to put in one spot and to get through, but I'm gonna need you to bear with me because it's a lot for me too, and I've just got to go step by step, one at a time.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So for the first one I'm gonna cite is the 353-844-3 and then the 353, you don't want me to do this one that we've already talked about?
[CUSTOMER][NEUTRAL] No, not that.
[CUSTOMER][NEUTRAL] I will provide you the date sir.
[CUSTOMER][NEUTRAL] No, I, you can do that, but.
[CUSTOMER][NEUTRAL] I'm asking you about the data service. I will provide you the data service and the bill amount.
[AGENT][NEUTRAL] OK perfect I'm putting in the request for the ones we already have the claim numbers for and then I will research the additional um claim numbers by the date of service once I'm done with this request.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so I have in the notes stating, and they're all gonna read just like this once we get all the claim numbers um.
[AGENT][NEUTRAL] But I have it stating provider has one claim that was submitted twice and denied for two separate reasons. He is looking for clarification about why the codes were denied for two different reasons claim number 353-8443 and 3539926. Callback number is [PII].
[CUSTOMER][POSITIVE] Yes, that is correct.
[AGENT][POSITIVE] Perfect. So what I'm doing here.
[CUSTOMER][NEGATIVE] And you sent this for review because uh there are two denials. One is initially premium not paid later on secondary is denied as non-go due to diagnostic service, right?
[AGENT][NEUTRAL] Um, I did not put what the denial codes were, just, um, the claim numbers on there, um, but I did state that they were denied for two separate reasons and so.
[CUSTOMER][NEUTRAL] For my confirmation, I'm asking you. One was for not premium, not paid, and the other was for that also because of diagnostic.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, for your confirmation, yes, that is exactly it. It was not a covered diagnostic. Mhm. You betcha. And so what I'm doing is I'm sending this one and then I can.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Not a current diagnosis.
[CUSTOMER][NEUTRAL] Not a diagnostic in the sense.
[AGENT][NEUTRAL] It said
[CUSTOMER][NEUTRAL] In the sense, the diagnosis code is not covered?
[AGENT][NEUTRAL] It is saying that they were not a here, let me go back into those remarks real quick.
[AGENT][NEUTRAL] It states that the medical test for the state of service is not a covered diagnostic test, therefore, no benefit is payable for this claim, and then it states the cover test include MRI, CAT scan, um, thyroid uptake test.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Medical test.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Cover tests include MRI, CAT scan, thyroid. Oh, at the top. I'm so sorry.
[CUSTOMER][NEUTRAL] Not that, not that. Sure.
[CUSTOMER][NEUTRAL] And details. Yeah.
[AGENT][NEUTRAL] The medical test for this date of service.
[CUSTOMER][POSITIVE] Not a problem.
[AGENT][NEUTRAL] Is not a covered diagnostic test.
[AGENT][NEGATIVE] Therefore, no benefit is payable for this claim.
[CUSTOMER][POSITIVE] That's thank you so much bye bye.
[CUSTOMER][NEUTRAL] So, initially for premium and later on for diagnostic test is not covered benefit.
[AGENT][NEUTRAL] Yes, and then so you have like some data services you want me to look up um to find those claim numbers so we can go through those as well, is that correct? Are they for Jonathan?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, I'll out for Jonathan.
[AGENT][NEUTRAL] OK, all for Jonathan. OK. So what is the date of service that we want to look at?
[CUSTOMER][NEUTRAL] What was the bill amount for this data service? Could you please let me know the claim number 8443?
[AGENT][NEUTRAL] 8443.
[AGENT][POSITIVE] Oh my gosh, I'm so sorry. I'm having trouble finding it now.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] I am, I'm pulling up the like original claim as it was sent in because mine just has like it broken down like 2190, 2190, 4023. So just save myself from adding up all of those individually, I'm just gonna pull it up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see the claim.
[AGENT][NEUTRAL] So it looks like the total bill amount on that claim I have is 726.81 as it was sent to us.
[CUSTOMER][NEUTRAL] 726.81.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Are you sure?
[AGENT][NEUTRAL] So yeah, that's what it says in box 28, total charge, 726.81.
[CUSTOMER][NEUTRAL] 726.81. Give me just a moment.
[CUSTOMER][NEUTRAL] Claim number 8443, right?
[AGENT][NEUTRAL] Yep, 8444, yes, I cannot talk but yes.
[CUSTOMER][NEUTRAL] 72681.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Just a moment, ma'am.
[AGENT][POSITIVE] No worries.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] And this includes data of service [PII] as well, right?
[AGENT][NEUTRAL] It looks like the only date of service I see on here is the [PII].
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Only [PII]
[AGENT][NEUTRAL] Oh, no, I see 2 at the bottom for the [PII], 2 codes on the [PII].
[CUSTOMER][NEUTRAL] 15,000, right? Yeah, OK, understood totally.
[AGENT][NEUTRAL] Yep.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Totally understood. OK. So now, could you please check for the next date of service?
[AGENT][NEUTRAL] Yes, um, let me move to that screen for you. What is the next data service we want to look at my friend?
[CUSTOMER][NEUTRAL] That is also [PII] for bill amount $882.63.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you give me that build out one more time? I'm gonna write it down as a note, but everything's individual, so I have to like manually add up all these numbers.
[AGENT][NEUTRAL] You said 800.
[CUSTOMER][NEUTRAL] 8
[CUSTOMER][NEUTRAL] $82.63.
[AGENT][NEUTRAL] 63 cents. OK, hang tight with me while I go through all of the claims and see which ones match.
[AGENT][NEUTRAL] OK, it's not that one. That one's only like $500.
[AGENT][NEUTRAL] 233.
[AGENT][NEUTRAL] Alright, 882.6. So I did find that claim. I have claim number 353-9233.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And for that claim number, would there be a duplicate on file that I need to start looking for?
[CUSTOMER][NEUTRAL] Yes, please, could you please try to look at uh I think there is as well.
[AGENT][NEUTRAL] OK, let me start pulling those up for you.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, that one's not it.
[AGENT][NEUTRAL] All right, I'm not showing another one on file that matches the total charges.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] The 800.
[AGENT][NEUTRAL] 40.
[AGENT][NEUTRAL] We just start at this top 11 more time just in case.
[AGENT][NEUTRAL] 888 that's the original.
[AGENT][NEUTRAL] No, I do see another one.
[AGENT][NEUTRAL] From you guys, but it has a different total charge on it.
[AGENT][NEUTRAL] It's not the 800, it's, it's different.
[CUSTOMER][NEUTRAL] But that, does that include the same claim and same procedure codes?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let me take a look at the two claims together. I'm sorry, I think I like made my computer mad cause it's frozen.
[AGENT][NEUTRAL] Appreciate your patience. I have to reopen the window to view those. hang tight while I get that restarted.
[CUSTOMER][POSITIVE] Not a problem.
[CUSTOMER][NEUTRAL] Like, uh,
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, so it looks like.
[AGENT][POSITIVE] Oh my gosh, I am so sorry. I just
[CUSTOMER][NEUTRAL] It looks like
[AGENT][NEGATIVE] Don't know why this isn't loading. I'm not sure. I have the two claims pulled up and now I can't remember which one matched your $800.
[AGENT][NEUTRAL] I believe it was this one ending in 33.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] It has let me see if any of these procedure codes match.
[AGENT][NEUTRAL] Alright, I'm not certain that these guys match, but I want to check something for you. 233.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Alright, so it looks like I'm just gonna open this up. It looks like we got 12345678 claims or 8, yeah 8 claims sent to us on [PII]. Do you know, are they all part of one claim or were they 8 individual claims?
[CUSTOMER][NEUTRAL] Mm I don't have that information.
[AGENT][NEUTRAL] OK, looks like they're all from.
[AGENT][NEUTRAL] From you all.
[CUSTOMER][NEUTRAL] Looks like they're all in one thing.
[AGENT][NEUTRAL] Well, it looks like.
[AGENT][NEUTRAL] They're all from this your same group, all 8 of them?
[CUSTOMER][NEUTRAL] Yeah, yeah, uh uh from the same group. I can uh tell you that.
[CUSTOMER][NEUTRAL] All are from [PII] Intervals now.
[AGENT][NEUTRAL] 92
[AGENT][NEUTRAL] Alright, so the claim that matched the 882.63, let me give you that claim number right now so I don't lose it on you again. I have claim number.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 353-923-3.
[CUSTOMER][NEUTRAL] That is the same claim number which you have provided me initially.
[AGENT][POSITIVE] Oh, I am so sorry. I, when it all deleted, I thought that I hadn't even given you the claim number and I was really worried that I lost it and I was, I mean, I was clearly trying to find out for you.
[CUSTOMER][NEUTRAL] I, I apologize. I, I thought like you are, you are searching for the second claim.
[AGENT][NEUTRAL] I am opening up all the claims to see if any of them match. So I'm just opening up every claim that's been sent to us instead of trying to
[CUSTOMER][NEGATIVE] Like, initially the claim getting denied for.
[AGENT][NEUTRAL] Search it in the system. I'm just trying to look at each claim sent to see if I can find a match, but.
[AGENT][NEUTRAL] You gotta bear with me because I gotta like open up every claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, but I had to restart my system. I'm so sorry. I don't know why I'm running into all the technical issues, um, so let me minimize this.
[AGENT][NEUTRAL] So it looks like.
[AGENT][NEUTRAL] This one.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Not from you guys.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] From here.
[AGENT][NEUTRAL] I don't have a lot more to go through. Hang on one second. I'm just looking at every claim that's been sent to us, and I'm pulling aside all the ones that have been sent from your group. So far I only see the one match with the same total charges, the one that we talked about earlier, um, but I still have about 6 more claims to just peek at and see if they're from your group or not, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That might be from our group itself.
[AGENT][NEUTRAL] Yeah, I think the only other ones I'm seeing so far are from different providers, but we facilities, but I still.
[AGENT][NEUTRAL] And I'm looking at everything that was submitted after the
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] I just have 4 more.
[AGENT][MIXED] I wish these all loaded so much quicker, but I really appreciate your patience.
[CUSTOMER][POSITIVE] Not a problem.
[AGENT][NEUTRAL] And then this will be the last one to look at.
[AGENT][NEUTRAL] All right, so I have all the claims that your group has submitted so far. The only claims I see with two matching totals on them are the ones that are the 72681, and then out of the other claims I have, I have one for 2379.
[AGENT][NEUTRAL] I have
[AGENT][NEUTRAL] 14.
[AGENT][NEUTRAL] 4758.
[AGENT][NEUTRAL] 882-63. We did talk about that one earlier, but I hadn't found a match for it.
[AGENT][NEUTRAL] Um, 572 40.
[AGENT][NEUTRAL] And then 7137, 4566, and 25, 68, but nothing else with matching totals.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I think that's the only duplicate claim I see on file for this patient.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Was that original one.
[CUSTOMER][NEUTRAL] 11 more, there is a 572 4 $57.04 right?
[AGENT][NEUTRAL] Yes, there was one for 572 40, you betcha.
[CUSTOMER][NEUTRAL] OK, so these all are double claims, right? Initially denied for premium not paid and later on secondary denied for like medical test for this data services not covered diagnostic test, therefore, no benefits is payable for this claim, right?
[AGENT][NEUTRAL] So that those are the duplicates I had we had listed for the charge of 72681. The one that is 57,240, it didn't have a duplicate, so there weren't any duplicates as far as denial codes, but I can look up that claim particularly and let you know what the denial code on that is.
[AGENT][NEUTRAL] So the one that was for the
[CUSTOMER][NEUTRAL] OK, so there are uh so.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Only duplicates are for, only duplicates are for the amount of $726.81.
[AGENT][NEUTRAL] Yes, and all the rest of them have different um charged amounts, so they're not duplicates.
[CUSTOMER][NEUTRAL] So different charge amount, that means what is it now? Either the now is premium not paid or the diagnostic test is not covered.
[AGENT][NEUTRAL] And so you're wanting to know about the total charge of 57,240, right? Just to make sure we're talking about the same one?
[CUSTOMER][NEUTRAL] 572 rest all, ma'am, excluding 72681 72681 has both it in house. I'm checking on the rest.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, uh, for 57,240, I have your claim number listed as 35329.
[AGENT][NEUTRAL] I'm sorry, 353-924-0.
[AGENT][NEGATIVE] And this one has two different denial codes listed on it. It says that the calendar year maximum for um sorry, the calendar year maximum on diagnostic services has been met, and the medical test for this state of service is not a covered diagnostic uh test, therefore, no benefits are payable. So it lists both those denials.
[CUSTOMER][NEUTRAL] So, so that means we can take one denial, right? We can take as medical test for the data service and not covered diagnostic tests. There were no benefit is payable. So these are non-covered in the patient's plan or provider's contract.
[AGENT][NEUTRAL] It's [PII] plan.
[CUSTOMER][NEUTRAL] Patience plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So 570,240 is also denied for medical test for this data, so it is not covered diagnostic. So could you please let me know about 88263?
[AGENT][NEUTRAL] Yes, you bet you. So that one, let me pull it up real quick. Your claim number is 353-923-3, um, and that one is just one code for the denial and it states, um, calendar year maximum on diagnostic service has been met.
[CUSTOMER][NEUTRAL] Calendar year maximum.
[AGENT][NEUTRAL] On diagnostic service.
[CUSTOMER][NEUTRAL] 4
[AGENT][NEUTRAL] Has been me.
[CUSTOMER][NEUTRAL] So this doesn't have any like uh medical test for the data is not diagnostic test.
[AGENT][NEUTRAL] No, they just list the one diagnostic code on or the one denial code on this.
[CUSTOMER][NEGATIVE] Not like that.
[CUSTOMER][NEUTRAL] Calendar maximum for the diagnostic service has been met, right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And that is like uh diagnostic testing for $100 once per calendar year and diagnostic testing for follow-up, that is $25.01 in [PII] and both have been met.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] Next, can we go ahead for
[CUSTOMER][NEUTRAL] Yeah, provide me for 572 40, 8263, and 72,680. For 72681, you're gonna send the inquiry, right?
[AGENT][NEUTRAL] Yes, I already submitted that inquiry for you for those 2 duplicates, so you can get some clarification there. And then I have 4 more claims that were submitted by your group if you want me to go through them.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] Alright, so I'm just gonna grab the next closest one. I have this one, the total on it was 2568.
[AGENT][NEUTRAL] I show the claim number is.
[AGENT][NEUTRAL] 353-9235.
[AGENT][NEUTRAL] And then on that one I have the denial stating.
[AGENT][NEUTRAL] The medical test for this state of service is not a covered diagnostic test. Therefore, no benefits are payable for this claim.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] the patient's plan.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let me know when you're ready for me to move on to the next one for you. All right, this one is going to be the total charge on it was the 4566, and we're looking at claim number 353-9230.
[CUSTOMER][POSITIVE] I'm ready.
[AGENT][NEGATIVE] Um, this one has the same thing. It says the medical test for the state of service is not a covered diagnostic test. Therefore, no benefits, um, is no benefit is payable for this claim.
[CUSTOMER][NEUTRAL] This is also not covered in the patient's plan, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And patients plan is unlimited hospital indemnity plan.
[AGENT][NEUTRAL] You betcha. Yes, sir.
[CUSTOMER][NEUTRAL] You can go ahead next.
[AGENT][NEUTRAL] Perfect. Next one, the total charge on it was $71.37 and the claim number is 353-924-9. This one is the same reason as the last.
[AGENT][NEUTRAL] The medical test for this state of service is not a covered diagnostic test for the uh therefore no benefit is payable for this claim.
[CUSTOMER][NEUTRAL] Unders
[CUSTOMER][NEUTRAL] Uh, OK, understood.
[AGENT][NEUTRAL] And then I only have one more after that, you just let me know when you're ready, OK?
[CUSTOMER][NEUTRAL] Not one more, I think so.
[CUSTOMER][NEUTRAL] Give me just a moment, not one more, I think so.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 1
[CUSTOMER][NEUTRAL] Yeah, I send you 137.
[AGENT][POSITIVE] I think you're right. I have 2 more.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, it was just hidden under the screen I was using, but you can still let me know whenever you're ready.
[CUSTOMER][NEUTRAL] 2516.
[CUSTOMER][NEUTRAL] So there are, I think, so 2379 and uh
[CUSTOMER][NEUTRAL] And which is, which one is left?
[AGENT][NEUTRAL] The 2379 and then the 4758 yep.
[CUSTOMER][NEUTRAL] 4750, right?
[CUSTOMER][NEUTRAL] OK. Go ahead with 2379.
[AGENT][POSITIVE] Perfect. I have 2379 pulled up for you. You're looking at claim number 353-9246.
[AGENT][NEUTRAL] And that has the same, hold on, let me make sure I hit enter. Uh yes, it has the same denial code as the last, the medical test for the state of service is not a covered diagnostic test. Therefore, no benefit is payable for this claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Next 4758.
[AGENT][NEUTRAL] Yep, and that one we're gonna be looking at claim number 353-9248.
[AGENT][NEGATIVE] And it has the exact same um denial code as the last. The medical test for the state of service is not a covered diagnostic test. Therefore, no benefit is payable for this claim.
[CUSTOMER][NEUTRAL] So that means only two line items have been denied like calendar year maximum have been met, that is for 5702 40 and uh
[CUSTOMER][NEUTRAL] One more was.
[AGENT][POSITIVE] I'm so sorry. I actually don't remember them individually like that, but I'd be more than happy to pull them back up.
[CUSTOMER][NEUTRAL] Yeah, uh, just a moment, I remember.
[CUSTOMER][NEUTRAL] No, no, no. I have that. Give me just a second.
[CUSTOMER][NEUTRAL] I have that.
[CUSTOMER][NEUTRAL] One was 8263.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So, so for that inquiry, how much time and time we need to allow?
[AGENT][NEUTRAL] Uh, for the callback, typically 24 hours, um.
[AGENT][NEUTRAL] So, tomorrow afternoon at the latest?
[CUSTOMER][POSITIVE] OK, thank you so much for that information and.
[AGENT][POSITIVE] Yes, absolutely.
[CUSTOMER][NEUTRAL] So it is, uh, IMA was initially, uh, initially it was IMA later on it is 90 degree benefits, right?
[AGENT][NEUTRAL] Um, for IMA?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yes, and you are the 90 degree benefits who pro uh you are the American Public Life who process the medical claims for IMA, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, for some of their policies we do.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And your good name, please?
[AGENT][NEUTRAL] Yes, my name is [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Just a second.
[AGENT][POSITIVE] No worries. My last initial is [PII].
[CUSTOMER][POSITIVE] Thank you so much I really appreciate your assistance. Um, that means a lot. Thank you so much.
[AGENT][POSITIVE] Hey, I really appreciate your patience, [PII]. Like it means the world to me as well. I appreciate you hanging out with me while we dug through all of that.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] And uh may I also get the conference number?
[AGENT][NEUTRAL] You bet you it's gonna be my name [PII] and then today's date.
[AGENT][NEUTRAL] Oh, I'm sorry, Ali B and then today's date.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So, we, the, those, those which are not covered like medical diagnostic, which you stated that medical test for this data service is not covered diagnostic test. There no benefit is payable for this claim, as these are not covered in the patient's plan as patient's plan is limited hospital and term policy, we can build those for member, right?
[AGENT][NEUTRAL] So because we're a supplemental plan we're not allowed to determine patient responsibility. I believe that's gonna be up to the provider's office.
[CUSTOMER][NEUTRAL] But that is not covered under the patients plan, right?
[AGENT][NEUTRAL] Yes, it is not covered under their plan, that is correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much bye bye.
[AGENT][POSITIVE] Hey my pleasure you have a great day bye bye.
[CUSTOMER][NEUTRAL] Bye bye.