AccountId: 011433970860
ContactId: 9bd80dbd-a490-417b-90ed-5029df7b1b30
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 409290 ms
Total Talk Time (AGENT): 155186 ms
Total Talk Time (CUSTOMER): 143910 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/19/9bd80dbd-a490-417b-90ed-5029df7b1b30_20250619T19:25_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling for provider to check on additional information about a claim that has been denied. Please note this call will be monitored and recorded for quality and training purposes.
[AGENT][NEUTRAL] May I have a callback number, please?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] [PII]. It's a direct line.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] And may I have the policy number?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] The member ID you're asking for?
[AGENT][NEUTRAL] Yes, the member's policy number.
[CUSTOMER][NEUTRAL] 01758742
[AGENT][NEUTRAL] May I have the patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] and the date of birth [PII].
[AGENT][NEUTRAL] And you're calling in for status of this member. May I please have the date of service and total bill?
[CUSTOMER][NEUTRAL] So it is [PII] with the bill amount of $25 even. Give me one second.
[CUSTOMER][NEUTRAL] The bill amount is
[CUSTOMER][NEUTRAL] $536 even.
[AGENT][NEUTRAL] And that is for 5425.
[CUSTOMER][NEUTRAL] 525, yes. 525.
[AGENT][NEUTRAL] No, I'm asking, is it for the date of service of [PII], which is 5425?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] And the total bill is 525 even.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] 536 even.
[AGENT][NEUTRAL] OK. Now, for.
[AGENT][NEUTRAL] For this state of service and that total bill, I have no claim on file.
[CUSTOMER][NEUTRAL] Can I provide you the claim number?
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] So it is 3606789.
[AGENT][NEUTRAL] And are you sure that's the correct total amount?
[CUSTOMER][NEUTRAL] Give me 1 2nd, I'll just check that once again.
[CUSTOMER][NEUTRAL] OK. So it is $316 even.
[AGENT][NEUTRAL] So the date of service is [PII] with the total bill charge of $316.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So for that claim, it's showing that it denied that office visits are not covered under the patient's plan.
[CUSTOMER][NEUTRAL] OK. As I can check in my OB, the CPT 99214 is denied as the service bill is not covered by the patient's policy and patient encountered for unspecified acute lower respiratory infection and physician rendered office or other outpatient visit for the evaluation and management service to the patient. So if the patient has any other active insurance?
[AGENT][NEUTRAL] I'm not sure if the member has any other active insurance, but for this policy, we do not cover office visits.
[CUSTOMER][NEUTRAL] OK. And the patient plan is causing the denial, right?
[AGENT][NEUTRAL] What do you mean the patient's plan is causing the denial?
[CUSTOMER][NEUTRAL] OK. Do you follow Medicare or Medicaid guidelines?
[AGENT][NEUTRAL] We follow our guidelines based off of the member's contract or policy.
[CUSTOMER][NEUTRAL] OK. So, American Public Life Insurance guidelines.
[AGENT][NEUTRAL] That is correct. It's based off of the member's policy.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. And is there any policy number or article number that you can provide me for those guidelines or there is none?
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] The policy number is the policy number that you gave me which is the member ID. So each policy has a different allowable or whatever choice they, they, they choose. So if this member does not have that benefit rider, it's denied.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And can I get the, may I know is the CPT valid and bill?
[CUSTOMER][NEUTRAL] there and
[AGENT][MIXED] The CPT is value is billable, but it's deniable because the member doesn't have it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And can I get the correct claim time limit and the address, please?
[AGENT][NEGATIVE] We have no timely filing.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the mailing address.
[CUSTOMER][NEUTRAL] And the mailing address?
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Can I have the appeal time limit and the address?
[AGENT][NEUTRAL] As I stated, there is no timely filing and any claim submission that is the mailing address that needs to be the claims need to be submitted to.
[CUSTOMER][NEUTRAL] OK. And is there any pay a specific appeal form required when submitting an appeal or just a formal letter?
[AGENT][NEUTRAL] You, if you're trying to submit the claim again, you will have to submit the claim, the EOB.
[AGENT][NEUTRAL] Just as a new claim.
[CUSTOMER][NEUTRAL] OK. And is there any of your attention?
[AGENT][NEUTRAL] But you have all rights to submit an appeal.
[AGENT][NEUTRAL] You have all rights to submit an appeal, but it's still gonna continue to deny, it's not covered. But if you would like to put attention appeals department, that would be correct as well.
[CUSTOMER][NEUTRAL] OK. And is there any appeal attention?
[AGENT][NEUTRAL] As I stated, appeals department.
[CUSTOMER][NEUTRAL] OK, got it. And can I have your name, please?
[AGENT][NEUTRAL] That for the call reference, it will be my first name [PII], spelled [PII] last initial [PII] and today's date. Is there anything else that I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] So initially your last name is [PII]?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK. And
[CUSTOMER][POSITIVE] Thank you so much for that all information and thank you so much for your assistance. Have a wonderful shift.
[AGENT][POSITIVE] You're welcome and thank you for calling American Public Life. Have a great day as well.