AccountId: 011433970860
ContactId: 8edcdc39-384e-4bb6-ae1c-b8abdb0a97ce
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 660190 ms
Total Talk Time (AGENT): 268837 ms
Total Talk Time (CUSTOMER): 275741 ms
Interruptions: 7
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/8edcdc39-384e-4bb6-ae1c-b8abdb0a97ce_20250213T17:26_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling for the provider to check on additional information about the claim that has been denied. Please note this call will be monitoring and recorded for quality and training purposes and also we sure you will be a clarification of the denial reason. Can you spell your name?
[AGENT][NEUTRAL] OK. Sure, it's [PII] last initial [PII] and your name is again?
[CUSTOMER][NEUTRAL] It's a [PII]
[AGENT][NEUTRAL] OK, and [PII], you say you're calling for claim status, correct?
[CUSTOMER][NEUTRAL] Yes, the clarification.
[AGENT][NEUTRAL] And what is that policy number?
[CUSTOMER][NEUTRAL] OK. So the policy number is 025099909.
[AGENT][NEUTRAL] OK, thank you, one moment.
[AGENT][NEUTRAL] And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] [PII]. Direct line?
[AGENT][NEUTRAL] OK, and verify the patient's name, date of birth.
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and what was the date of service and amount of the charge?
[CUSTOMER][NEUTRAL] OK, the date of service is in [PII].
[CUSTOMER][NEUTRAL] Let me open that. One moment. We'll provide the bill amount.
[CUSTOMER][NEUTRAL] So the bill amount is $212.50.
[AGENT][NEUTRAL] You said $212.50?
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, and you are calling from?
[CUSTOMER][NEUTRAL] It's physician
[CUSTOMER][NEUTRAL] assistance and I was like nursing.
[AGENT][NEUTRAL] I'm sorry, what's the name of the provider's office?
[CUSTOMER][NEUTRAL] Coastal Pediatric Associates.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, see, I'm showing that claim processes, uh, policy provides no benefits for the treatment of conditions other than for sickness or an injury as defined by the policy.
[AGENT][NEUTRAL] Meaning per the explanation of benefits, it was not for sickness or uh for sickness, so it is not covered under the policy.
[AGENT][NEUTRAL] What?
[CUSTOMER][NEUTRAL] So you're saying the code is not covered under the patient's policy?
[AGENT][NEUTRAL] Correct, part of the patient's policy, it is not covered.
[CUSTOMER][NEUTRAL] So, I do have the results in my end stating it the patient encounter for wheelchair visit and the provider from pediatric comprehensive preventive medicine reevaluation and management of individual including an age and gender appropriate history, examination, counseling, or anticipatory guidance or risk factors, protection, interventions, and ordering of laboratory procedures established patient. So, is there any possible to this in the inquiry process?
[AGENT][NEUTRAL] No, you can submit an appeal if you'd like. You have up to 180 days from the time the claim was processed to submit an appeal. You must submit a letter stating the reason for the appeal, and you can also attach any other documents for review.
[CUSTOMER][NEUTRAL] And also we need to submit a contact claim with appropriate procedure code or not?
[AGENT][NEUTRAL] Uh, any information you would like to uh submit for review, we can't tell you on submitting a corrected claim, but if you're submitting an appeal, you must submit a letter stating the reason for the appeal, as well as you can submit any additional documents you may have.
[CUSTOMER][NEUTRAL] OK, so could you please provide the correct mailing address for documentation purpose?
[AGENT][NEUTRAL] The address for to submit an appeal is [PII].
[CUSTOMER][NEUTRAL] Oh OK. One moment.
[CUSTOMER][NEUTRAL] [PII]. And what about the current time different limit?
[AGENT][NEUTRAL] Sir, it's not for correction. If you're submitting a corrected claim, then you must submit a letter stating the reason for the correction, and there's not a time limit for a correction.
[CUSTOMER][NEUTRAL] OK, so there is no time limit for character claim, correct?
[AGENT][NEUTRAL] Correct. And like I said, if you're submitting a corrected claim, you must submit a letter stating the reason for the correction.
[CUSTOMER][NEUTRAL] And what about the mailing address for documentation purpose?
[AGENT][NEUTRAL] It's the same as the address I just gave you, the [PII].
[CUSTOMER][NEUTRAL] Uh, OK, OK, got it.
[CUSTOMER][NEUTRAL] And what about the pill time limit?
[AGENT][NEUTRAL] Uh, you have up to 180 days from the time the claim was processed to submit an appeal.
[CUSTOMER][NEUTRAL] And is there any specific form is required or not for an appeal?
[AGENT][NEUTRAL] I'm sorry, say again.
[CUSTOMER][NEUTRAL] While submitting an appeal, is there any form is required or not?
[AGENT][NEUTRAL] No, but you must submit a letter stating the reason for the appeal.
[CUSTOMER][NEUTRAL] OK. And what are the guidelines do you follow?
[AGENT][NEUTRAL] I'm not understanding what you're asking, what guidelines?
[CUSTOMER][NEUTRAL] You follow Medicaid or Medicare, or is there any specific guidelines do you follow?
[AGENT][NEUTRAL] No, we don't, we don't follow Medicare guidelines.
[CUSTOMER][NEUTRAL] OK. Which gas do you follow?
[AGENT][NEUTRAL] We follow the guidelines that are under our company. If you submit an appeal, you have up to 180 days for the patient's policy services other than for sickness or injury is not covered. That is per the patient's policy with our company.
[CUSTOMER][NEUTRAL] So the, so the one guidelines is American Public Airlines, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So the denial CBT is available code or not under this American public guidelines?
[AGENT][NEUTRAL] Per the patient's policy is not covered. So, I'm not understanding what you're asking. Per the patient's policy with our company at APL that's not covered.
[CUSTOMER][NEUTRAL] So, OK, one moment.
[CUSTOMER][NEUTRAL] Please, please.
[CUSTOMER][NEUTRAL] OK. So, I'm asking the question is the denial CBT is a billable code or not under this American public guidelines?
[AGENT][NEUTRAL] Per the patient's policy with American Public Life, it is not covered.
[CUSTOMER][NEUTRAL] I'm ready for the policy reference number.
[AGENT][NEUTRAL] We don't give reference numbers. If you like, you may use my name in today's date, and Parker, is there anything else I can assist you with today? OK.
[CUSTOMER][NEUTRAL] So, one moment.
[CUSTOMER][NEUTRAL] Yes, I do, I do have one more claim with the
[AGENT][NEUTRAL] Same patient or different patient?
[CUSTOMER][NEUTRAL] Same member
[AGENT][NEUTRAL] OK. What's that data service and amount of the charge?
[CUSTOMER][NEUTRAL] Yes, it's a.
[CUSTOMER][NEUTRAL] OK. Give me one moment. I'll pull that account. One second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] So the data service is a
[CUSTOMER][NEUTRAL] [PII]. The total bill amount is $200 even.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Uh, the same. It was processed as, uh, services other than for sickness or injury is not covered per the policy.
[CUSTOMER][NEUTRAL] So for this one also, the code is not covered under the patient's policy. Now we need to
[CUSTOMER][NEUTRAL] Check with the policy and submit the appropriately, correct? Or we need to submit?
[AGENT][NEUTRAL] Per the patient's policy is not covered. You are more than welcome to submit an appeal, as again, you must submit a letter stating the reason for the appeal, and you can attach any documents for review. If you're submitting a corrected claim, then you must submit a letter stating the reason for the correction, and there's no time limit for corrected claim.
[CUSTOMER][NEUTRAL] OK, one moment. So,
[CUSTOMER][NEUTRAL] Code is
[CUSTOMER][NEUTRAL] 9939. 1 moment.
[CUSTOMER][NEUTRAL] So the CPT is 99391, correct?
[AGENT][NEUTRAL] Well, neither was covered. Services other than for a sickness or an injury is not covered. That is how it was processed per the patient's policy. If it's not for sickness or an injury, it's not and I'm sorry, and I'm explaining to you that per the policy, if it's not for sickness or injury, it's not covered.
[CUSTOMER][NEUTRAL] I'm asking about the CPA.
[CUSTOMER][NEUTRAL] How many times will you explain?
[CUSTOMER][NEUTRAL] OK, how many times you will you explain? I understood, right, what you are saying one time only, but I'm asking about the people. I'm not asking the keeping that you only.
[AGENT][NEUTRAL] Well you, well, sir, I apologize, but you keep asking the same, you keep asking the same question, and I've explained it to you the same thing.
[CUSTOMER][NEUTRAL] OK. I'm asking the question is what was the CPT? Is it 99?
[CUSTOMER][NEUTRAL] 391 or not. That's my question. But you are saying the full.
[AGENT][NEUTRAL] Well, that's the claim that was submitted, that was the claim that was submitted and per the claim, the service is not, not for a sickness or an injury, so it's not covered under the policy.
[CUSTOMER][NEUTRAL] Yeah, got it. So.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] OK. So I do have the code of not in my end stating is the patient encounter for wheelchair visit and the provider perform periodic comprehensive, preventive medicine, reevaluation and management of individual including an age and gender appropriate history, examination, counseling, or anticipatory guidance or risk factor reduction interventions, and the ordering of laboratory or diagnostic procedure established patient to the patient. So for this also, you didn't take the query process, correct?
[AGENT][NEUTRAL] No, it's not going to be reprocessed because it's not covered if it's for uh anything except for a sickness or injury.
[CUSTOMER][NEUTRAL] So for this also the call reference number and your name and today's date, correct?
[AGENT][NEUTRAL] You can use my name in today's date, correct.
[CUSTOMER][POSITIVE] So that's it for today. Thank you so much information. Thank you for asking. Have a good day. Bye-bye.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] You're welcome, [PII], and thank you for calling APL. Bye.