AccountId: 011433970860
ContactId: 8a0ca0c4-76fc-48f2-9ebf-a1a81a0b625f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1766709 ms
Total Talk Time (AGENT): 565672 ms
Total Talk Time (CUSTOMER): 391408 ms
Interruptions: 5
Overall Sentiment: AGENT=0.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/23/8a0ca0c4-76fc-48f2-9ebf-a1a81a0b625f_20250623T19:05_UTC.wav
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[AGENT][NEUTRAL] Afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, I'm [PII] calling from the provider's office to check on the claim status.
[AGENT][NEUTRAL] OK, you said that your name is [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and you're needing to check claim status, is that also correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, [PII], I can help you with that. Um, one moment, please.
[AGENT][NEUTRAL] And [PII], what is a good call back number for you?
[AGENT][NEUTRAL] [PII], what is your callback number?
[CUSTOMER][NEUTRAL] Callbacker.
[CUSTOMER][NEUTRAL] Yeah, callback is.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And how many claims do you have to check status on today?
[CUSTOMER][NEUTRAL] One.
[CUSTOMER][NEUTRAL] Can I have your name?
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Again, my name is [PII] and my name in today's date will also be your call reference number.
[AGENT][NEUTRAL] And [PII], what is your patient's policy number?
[CUSTOMER][NEUTRAL] Yeah, the policy number is
[CUSTOMER][NEUTRAL] 01834900.
[AGENT][POSITIVE] Thank you one moment.
[AGENT][NEUTRAL] And any information that I do provide for you today, [PII] will be a verification of benefits and not a guarantee of payment. Uh, what is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII] after April.
[CUSTOMER][NEUTRAL] Uh, patient name is [PII]. Date of [PII]. Date of service, [PII].
[AGENT][NEUTRAL] And total bill amount.
[CUSTOMER][NEUTRAL] Um, $290 even.
[AGENT][NEUTRAL] 290. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you one moment.
[AGENT][NEUTRAL] And you did say data services for [PII], is that also correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you. One moment.
[AGENT][NEUTRAL] Bear with me just a moment please, [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, [PII]. So I have, OK, so this claim was received.
[AGENT][NEUTRAL] The received date on the claim.
[AGENT][NEUTRAL] Well, I'll tell you what, first verify the tax ID number for me, please.
[CUSTOMER][NEUTRAL] Um, tax ID [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Breast health
[AGENT][POSITIVE] Yes, ma'am. Thank you. OK.
[AGENT][NEUTRAL] So this claim was received on [PII].
[AGENT][NEGATIVE] It was processed and denied on [PII].
[AGENT][NEUTRAL] The claim number is 360.
[AGENT][NEUTRAL] 5434.
[AGENT][NEUTRAL] And the denial remark states that office visits.
[AGENT][NEUTRAL] are not covered by the above number policy?
[AGENT][NEUTRAL] And the other
[CUSTOMER][NEUTRAL] One minute.
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] For, what is the amount?
[AGENT][NEUTRAL] What is the code? What are the two codes on the claim form?
[AGENT][NEUTRAL] [PII], are you pulling that information?
[CUSTOMER][NEUTRAL] Yeah, one moment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, 99214 and 36415.
[AGENT][NEUTRAL] OK, so 99214, that code was denied as office visits are not covered under this policy.
[AGENT][NEUTRAL] And give me just a moment.
[AGENT][NEUTRAL] Do you mind letting me place you on a brief hold for just a moment, please?
[CUSTOMER][POSITIVE] Yeah, take your time.
[AGENT][POSITIVE] Thank you so much. One moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], it's [PII]. How are you today?
[CUSTOMER][NEUTRAL] I'm fine thanks how are you?
[AGENT][NEUTRAL] I'm all right. Can you please look at a claim because I, I do not understand this claim remark for this particular.
[AGENT][NEUTRAL] Claim.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] The policy number is 1,834,900.
[AGENT][NEUTRAL] And [PII] is on claim number 360.
[AGENT][NEUTRAL] 5434.
[AGENT][NEUTRAL] The patient is [PII].
[AGENT][NEUTRAL] So I get the office visits are not covered. The other code is for a venal puncture.
[AGENT][NEGATIVE] And that denial paragraph.
[AGENT][NEUTRAL] Says that we sent.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] We've sent a release of authorization.
[CUSTOMER][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] For medical providers?
[CUSTOMER][NEUTRAL] Yeah, so it looks like we sent out documentation to them to complete. It looks like we sent out an authorization form for them to sign and date along with information regarding the name.
[CUSTOMER][NEUTRAL] Um, addressing and help a number of the medical providers. And so once the insured sends back that information completed to us, then we'll, they'll be able to um continue processing the claim.
[AGENT][NEGATIVE] But we received the claim form, OK, but we've received the claim from the provider that's what I'm not understanding.
[AGENT][NEGATIVE] And we denied part of it as office visits are not covered and then we're requesting that other for a venna puncture.
[AGENT][NEUTRAL] And the provider filed the claim.
[CUSTOMER][NEUTRAL] Yes, it looks like we're needing to get mhm so in order for us to get additional information for the claim, the insured has to authorize that and if we don't have an authorization on file then the provider will not respond to us if we have like if we're asking for additional information.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I've just never seen this.
[AGENT][NEUTRAL] Code used
[AGENT][NEUTRAL] On a meddling policy when the provider filed the claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, it just, it's just for us for us to be able to correspond back with the provider. It's just because of the HIPAA.
[CUSTOMER][NEUTRAL] If it's any additional information regarding the claim, then unless we have an authorization on file from the insured, then they will not respond to us.
[AGENT][NEUTRAL] OK, so I just read that remark, that full paragraph to this lady on the line?
[CUSTOMER][NEUTRAL] Um, [PII]t's see, yes, yeah, it's always starting on the second line, um.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah, so she should have received and let's see what date this claim was processed.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh, she has she not received any of those documents?
[AGENT][NEUTRAL] The doctor's office?
[CUSTOMER][NEUTRAL] But what was this?
[AGENT][NEUTRAL] I'm talking to the doctor's office. No, I'm talking to the provider that filed the claim.
[CUSTOMER][NEUTRAL] The, are you talking to the insured or the doctor?
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK. I know I thought you were talking to the insured, um.
[AGENT][NEUTRAL] Yeah, no, no, no. The doctor's office.
[CUSTOMER][NEUTRAL] Uh yes. Um, give me just a second. Let me just take a look here.
[AGENT][NEUTRAL] Yeah, that's why I was, I mean, I was just confused if the doctor's office filed the claim.
[AGENT][NEUTRAL] I've, I've just not seen this remark on a med link claim.
[AGENT][NEUTRAL] When a provider file the claim.
[CUSTOMER][NEUTRAL] Actually, do you mind if I put you on hold for just a second while I just take a look and see what we sent?
[AGENT][POSITIVE] Yeah, sure. Yeah, no, no, yeah, that would be great. I, I, yeah, cause I was trying to avoid a hub ticket, but I also just
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Didn't know if that remark was correct.
[AGENT][NEUTRAL] Kind of
[CUSTOMER][NEUTRAL] OK, sure, give me just a second.
[AGENT][NEUTRAL] OK, thanks, [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, sorry about that, [PII] are you still there?
[AGENT][NEUTRAL] Oh, that's OK. Yeah, I am. Uh-huh.
[CUSTOMER][NEUTRAL] Yeah, so I checked with the um adjuster and yes, the code is correct that we normally use this code for a provider claim you know it's a provider claim, but because we need additional information from them and that in order to get it we need an authorization on file for the physician to respond back to us.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. All right.
[AGENT][NEUTRAL] OK, because the claim and also just an FYI the claim, whatever claim document was received is not up under that claim number. I mean like.
[AGENT][NEUTRAL] When we do the shortcut from EOBI clicking on the claim number to have the documents opening on base, you know.
[AGENT][NEUTRAL] The claim is not under that claim number.
[AGENT][NEUTRAL] It's only a provider EOB and a dental EOB. I mean, I mean, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The EOB to the insured, but there's not a claim.
[AGENT][NEUTRAL] The claims information is not in.
[CUSTOMER][NEUTRAL] Oh OK, yeah, sometimes you have to open it up like in like the policy under the policy number sometimes that's what I'll do and then I'll, and usually all the documents should be under the policy number if it's not under the claim number.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, well.
[AGENT][NEUTRAL] Yeah, but we don't know which is which when we're on a call, when you do it like that. There's a lot of claim, it won't.
[CUSTOMER][NEUTRAL] Oh yeah. You can go by the reported date.
[AGENT][NEUTRAL] You know what I mean? They're all just.
[CUSTOMER][NEUTRAL] That that's how I just match it up by the reported date and um for that claim number and sometimes they'll have the claim number listed too when you look at under the policy um I don't know why it does that sometimes but yeah that's just how I sometimes go around it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Gotcha. All right. Well, thank you for checking for me on that. I appreciate you.
[CUSTOMER][POSITIVE] Sure, you're welcome.
[AGENT][POSITIVE] OK, [PII]. Have a good afternoon.
[CUSTOMER][POSITIVE] Uh thanks you too.
[AGENT][POSITIVE] Thanks, thanks, bye bye.
[CUSTOMER][NEUTRAL] Bye-bye.
[AGENT][POSITIVE] [PII], thank you very much for holding for me.
[AGENT][NEUTRAL] [PII], are you still there?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so first off, the first code, as I explained to you, the office visit is not covered. The other code was denied, and I will be happy to read you the remark.
[AGENT][NEUTRAL] Receipt of your claim is it not.
[CUSTOMER][NEUTRAL] I'm sorry, you're very far from the mic. I, I can't hear you.
[AGENT][NEUTRAL] No, [PII], I'm, I'm right on the microphone.
[AGENT][NEUTRAL] So it must be something on your end.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes ma'am. Can you hear me?
[CUSTOMER][NEUTRAL] Yeah, now it's fine. So, when was it denied actually?
[AGENT][NEUTRAL] Let me go back and give you that information again.
[AGENT][NEGATIVE] It was denied on [PII]. It was received on [PII], denied on [PII]. The first reason for the denial is office visits are not covered, and the second remark denial remark for the second code states receipt of your claim is acknowledged. However, in order to provide further consideration of this claim.
[AGENT][NEUTRAL] We will need to request additional information from the patient's healthcare provider and authorization to allow the disclosure of protected health information has been mailed to the patient. Once this form is returned to us along with the information regarding the names, addresses, and telephone numbers of the medical provider, we will request additional information to continue reviewing your claim.
[CUSTOMER][NEUTRAL] One minute.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] So 36415 code was denied for additional information.
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] We are.
[CUSTOMER][NEUTRAL] What additional information is needed?
[AGENT][NEUTRAL] We're awaiting the signed release that was sent to the patient.
[AGENT][NEGATIVE] To be returned to us.
[CUSTOMER][NEUTRAL] Sorry, which one?
[AGENT][NEUTRAL] What is your question?
[CUSTOMER][NEUTRAL] OK. Well, you have any?
[CUSTOMER][NEUTRAL] What is the name of the, the document which you need to receive from the patient signed?
[AGENT][NEUTRAL] We mailed to the patient a form to be completed with the requested information that I just read to you and we're waiting to receive that back from the patient.
[CUSTOMER][NEUTRAL] Yeah, that is what I can understand that you have sent a form to the patient, but uh I'm asking which additional info is mentioned in that.
[AGENT][NEUTRAL] It's an authorization, yes.
[AGENT][NEUTRAL] An authorization?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] To allow the disclosure of protected health information.
[CUSTOMER][NEUTRAL] OK. Authorization to disclose?
[AGENT][NEUTRAL] Protected health information.
[AGENT][NEUTRAL] And if you need a copy of the explanation of benefits for you with those remarks on there that I read to you, you can use that claim number that I gave you and print that by going to our portal.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And using that claim number and the website for our portal is [PII].
[CUSTOMER][NEUTRAL] Uh, can you fax, uh, UB?
[AGENT][NEUTRAL] So you can't print it, is that correct? from the website that I just gave you?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes, you can print it or no, you can't print it.
[CUSTOMER][NEUTRAL] Yeah. Can I have the
[CUSTOMER][NEUTRAL] No, I, we are unable to. So, could you please take up our fax number and fax COB?
[AGENT][NEUTRAL] I can in a moment once I get the explanation of benefits pulled up.
[CUSTOMER][NEUTRAL] Thank you. And may I know the timely filing limit to send this uh additional information and resubmit the claim?
[AGENT][NEUTRAL] Uh, the claim does not need to be, it's not that the claim needs to be resubmitted. If you're wanting to file an appeal, you must file it within 180 days from the date of the decision.
[AGENT][NEUTRAL] And it must be sent in.
[CUSTOMER][NEUTRAL] OK. So what is the time limit for sending this additional info?
[AGENT][NEUTRAL] Mm
[AGENT][NEGATIVE] There is no timely filing for that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So only if we need to appeal, we can do it within 180 days.
[AGENT][NEUTRAL] Correct, and you must send it in writing and put it to attention appeals department.
[AGENT][NEUTRAL] Excuse me.
[CUSTOMER][NEUTRAL] Appeal address, please.
[AGENT][NEUTRAL] The same as the claims mailing address. What address do you have for claims?
[CUSTOMER][NEUTRAL] Uh, actually, we need to get it from the rep directly for the appeal specifically on this call, so I need the address now.
[AGENT][NEUTRAL] [PII], [PII], [PII]. The zip code is [PII].
[CUSTOMER][NEUTRAL] I'm sorry. Could you please repeat it again, the [PII] number?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] And what is your fax number, [PII]?
[CUSTOMER][NEUTRAL] Yeah, the fax number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and then does it need to be put to your attention?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And is your name spelled [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and again that fax number is [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK [PII], so I have just sent that to you, so you should be receiving that very soon.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. And is there anything?
[CUSTOMER][NEUTRAL] And the dollar amount that was uh
[CUSTOMER][NEUTRAL] Yeah, so the amount that was denied uh was that uh $290 right?
[AGENT][NEUTRAL] That is the total bill amount on this claim.
[CUSTOMER][NEUTRAL] For both the goods.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're very welcome.
[CUSTOMER][NEUTRAL] And uh
[AGENT][NEUTRAL] Do you have another question?
[CUSTOMER][NEUTRAL] Um, can I get the call reference?
[AGENT][NEUTRAL] My name and today's date.
[AGENT][NEUTRAL] And is there anything else I can help you with?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] No, thank you. That's all the information needed.
[AGENT][POSITIVE] OK, [PII]. Well then, thank you for calling APL and I hope that you have a nice rest of your day.
[CUSTOMER][POSITIVE] Thanks you too.
[AGENT][POSITIVE] Yes, ma'am. Thank you.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] And hello?
[AGENT][NEUTRAL] Hello. Yes, ma'am.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Yeah. So actually, I just want to confirm this is uh denied as non-covered as per patient's plan, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So this is uh denied it through APL or Medicare?
[AGENT][NEUTRAL] You're speaking with APL.
[CUSTOMER][NEUTRAL] OK. And uh can you just confirm?
[AGENT][NEUTRAL] This policy has nothing to do with Medicare.
[CUSTOMER][NEUTRAL] OK. And uh can you just confirm if any of the CBT codes was uh paid previously?
[AGENT][NEUTRAL] This is the we went over the claim that was received and the remarks on how it was processed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we can appeal for that, uh,
[CUSTOMER][NEUTRAL] Second code, right?
[AGENT][NEUTRAL] What code are you referring to as the second code?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] That is the one that I read you the remark that we are awaiting on the authorization to be returned to us from the patient.
[CUSTOMER][NEUTRAL] Yeah, OK. So the other code 99214, we can appeal for that.
[AGENT][NEUTRAL] If you choose to file an appeal, it must be sent to that claims address that I gave you. Attention appeals department, and it must be filed within 180 days from the date of the decision that I gave you.
[CUSTOMER][NEUTRAL] OK. So it's uh [PII]. It's still, we have time. It's not yet 180 days, so we can send the appeal still.
[AGENT][NEUTRAL] And is there anything else that I can help you with?
[CUSTOMER][POSITIVE] Um, no, thank you, [PII]. That's all the information needed. You have a great day.
[AGENT][POSITIVE] Yeah. Well, you're very welcome and I hope you have a nice day too, and thank you again for calling APL.
[CUSTOMER][POSITIVE] Thanks. Bye.
[AGENT][POSITIVE] You're welcome. Bye-bye.