AccountId: 011433970860
ContactId: 8f430f64-0836-4103-954c-9b15f31a6c3a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 553609 ms
Total Talk Time (AGENT): 150523 ms
Total Talk Time (CUSTOMER): 163122 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/8f430f64-0836-4103-954c-9b15f31a6c3a_20250416T17:57_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling from the office, uh, Charlesville Rad Limited to get clarification on the denied claim.
[AGENT][NEUTRAL] OK, well, I'll be more than happy to help you with the denial of clarity. And [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] It is [PII]. That's a direct line. And the policy number is going to be [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Yeah, [PII]. That's correct.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the claim number you'd like me to look at with you?
[CUSTOMER][NEUTRAL] Yeah, actually, the
[CUSTOMER][NEUTRAL] Proportional claim which was denied for
[CUSTOMER][NEUTRAL] And it is 354-95999.
[CUSTOMER][NEGATIVE] Actually, it is denied for maximum benefit for time period reach.
[AGENT][NEUTRAL] OK, so what questions did you have?
[CUSTOMER][NEUTRAL] So that we have submitted the.
[CUSTOMER][NEUTRAL] Yeah, for this, you know, we have submitted the uh the character claim. We have updated the diagnosis code for this, uh.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] But the CPT 93971, we have updated diagnosis code as M as in Mike 79.604 and R as in Romeo 79.1. After submission of the claim, you know, we have received the denial stating it is a duplicate.
[CUSTOMER][NEUTRAL] How come it's possible?
[AGENT][NEUTRAL] Because it's still outpatient and the outpatient max has been met.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So unless it changes to inpatient, as in they're admitted to the hospital, they've used all their outpatient benefits. So, so we cannot pay more than the max, the max is the most.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] If you don't mind, could you please give me a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, uh, thank you so much for your patience, and I actually, you know, uh, the visitor, it is not an outpatient. It's an emergency.
[AGENT][NEUTRAL] Was the patient admitted to the hospital?
[CUSTOMER][NEUTRAL] But you deny the claim as.
[CUSTOMER][NEUTRAL] Let me check on.
[AGENT][NEUTRAL] If the patient was not admitted to the hospital, it's still considered outpatient. The difference between outpatient and inpatient is the admission. So unless the patient was admitted into the hospital, it is still considered outpatient and that max has been used.
[CUSTOMER][NEUTRAL] OK and.
[CUSTOMER][NEUTRAL] Yeah, thank you so much for, for the information, [PII], but actually we have updated the diagnosis code, you know, after, uh, the collecting the updating the diagnosis code, the denial has to, uh, has to be as outpatient benefit for this calendar has been met, but however, the denial is like duplicate.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Don't you feel it's contradict?
[AGENT][NEUTRAL] So what I'll do is get a claims examiner on the line to explain this further for you. I understand that you changed the codes, but if the codes are still outpatient codes, it that benefit has been used. So, I'll get an examiner on the line to go over this with you further, OK?
[CUSTOMER][NEUTRAL] No, actually, what I'm trying to say is, uh, after updating the diagnosis code, still you're denying the claim, uh, the outcome is, it has to be like outpatient, uh, max has been met, but, uh, the claim was denied for duplicates, so that's the reason I was confused.
[AGENT][NEUTRAL] It was a duplicate because the original claim was denied because the outpatient benefit was used. So yes, you changed the codes, but the codes are
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Unless they're admitted into the hospital and it it becomes inpatient, everything else is outpatient and they've used their benefits for outpatient. So if you change the codes, it's still outpatient and we have already paid the max.
[CUSTOMER][NEUTRAL] OK, I understand.
[CUSTOMER][NEUTRAL] Yeah, that's
[CUSTOMER][POSITIVE] If you don't need to do this give me a moment, [PII]. It's a good one.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much for your patience. Uh, [PII], can I have the apple mailing the time?
[CUSTOMER][NEUTRAL] Uh, and I want to know that, is that the patient responsibility?
[AGENT][NEUTRAL] So, the appeal is 180 days from the denial date and we don't determine patient responsibility because we're not the major medical insurance company.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what about the uh mailing address or the fax number?
[AGENT][NEUTRAL] Um, so the mailing address for appeals is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] That's
[AGENT][NEUTRAL] And that will be attention APL appeals department.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Thank you. And can I have the card reference number and the spelling for your name?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII], and my name is [PII]
[CUSTOMER][POSITIVE] OK, once again, thank you so much for the information assistance, [PII]. Have a wonderful day. Take care. Bye. Thank you.
[AGENT][NEUTRAL] You're welcome, [PII]. Was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] No no, I'm good, thank you.
[AGENT][POSITIVE] Alright, thanks for calling APL. Bye bye.