AccountId: 011433970860
ContactId: a410813c-b760-4feb-84f0-54761a6f5508
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 855159 ms
Total Talk Time (AGENT): 343190 ms
Total Talk Time (CUSTOMER): 433419 ms
Interruptions: 7
Overall Sentiment: AGENT=0.8, CUSTOMER=1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/a410813c-b760-4feb-84f0-54761a6f5508_20250210T13:48_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], good morning. My name's [PII]. I'm calling from a provider's office, um, pardon me, there was a claim, uh, that you guys had been denying because you weren't receiving the primary EOB, um, but I had faxed that information, so I guess I just need to confirm in fact that you did receive it or did not receive it.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Well, it would be my pleasure to assist you, [PII]. What is a good callback number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, [PII]. And what is the policy number for the patient?
[CUSTOMER][NEUTRAL] Policy number is.
[CUSTOMER][NEUTRAL] 02432958 M as in Mary L as in Larry 8.
[AGENT][NEUTRAL] Thank you and the patient's name and date of birth, please, ma'am?
[CUSTOMER][NEUTRAL] [PII], date of birth is [PII].
[AGENT][POSITIVE] Alright thank you and the date of service please ma'am.
[CUSTOMER][NEUTRAL] Date of service is.
[CUSTOMER][NEUTRAL] [PII] and the bill amount was $397.32.
[AGENT][NEUTRAL] And the name of the facility?
[CUSTOMER][NEUTRAL] Dermatology Associates.
[AGENT][NEUTRAL] I'm checking, bear with me just one second.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yeah, I am not showing that EOB received. Did you fax it, you said?
[CUSTOMER][POSITIVE] Yeah, yes ma'am, yep, certainly did uh and I.
[CUSTOMER][NEUTRAL] To receive a fax confirmation um that it was received. I sent it [PII].
[CUSTOMER][NEUTRAL] I'm sorry, [PII], forgive me, it's Monday morning.
[AGENT][NEUTRAL] January.
[CUSTOMER][POSITIVE] [PII], yes, that's correct.
[CUSTOMER][NEUTRAL] Maybe I need more coffee in my life.
[AGENT][NEUTRAL] OK, bear with me just one second. I'm checking on that.
[CUSTOMER][POSITIVE] Thanks.
[AGENT][NEUTRAL] It looks like we did receive it.
[AGENT][NEUTRAL] Um, I
[AGENT][NEUTRAL] Do apologize, but there's still, it was anything applied to the deductible or copay or co-insurance for the 11102 or the 17,000?
[CUSTOMER][NEUTRAL] No, they're all zeros on the EOB, um, and.
[CUSTOMER][NEGATIVE] Two denials office visits are not covered, so the office visit portion I'm assuming won't get processed, but then the other two codes said that it was denied because I hadn't received the EOB.
[CUSTOMER][NEGATIVE] So it's not been processed, it's just been denied.
[AGENT][NEUTRAL] I mean, on the primary insurance, was there a, a co-pay or deductible?
[CUSTOMER][NEUTRAL] Oh, I'm sorry, forgive me let me see.
[AGENT][NEUTRAL] Right
[CUSTOMER][NEGATIVE] Yeah jeez, maybe I need to go home right um.
[AGENT][POSITIVE] No, you're good.
[CUSTOMER][NEUTRAL] No, there was a payment, there was a payment made, um, but there was 60 applied to a co-pay.
[AGENT][NEUTRAL] Because on the see, OK, I see the copay, but.
[AGENT][NEUTRAL] So, I'm looking at this sideways, so bear with me just a second. I can't see. There we go.
[CUSTOMER][NEUTRAL] You're fine, yeah, they made a payment of $93.59.
[AGENT][NEUTRAL] So what they're saying is they need a detailed explanation of benefits. Now on this EOB it does show the copay of $60 but it doesn't just uh say what code it's on.
[CUSTOMER][NEUTRAL] Oh, it's, it's uh it's detailed. I'm looking at it. I don't know what you guys are looking at, but.
[AGENT][NEUTRAL] Can you see, can you see what CPT code the $60 was applied to?
[CUSTOMER][NEUTRAL] Yes ma'am, the office visit, the 99213.
[AGENT][NEUTRAL] OK, let me look at it again. It, uh, like you said, it is Monday.
[CUSTOMER][NEUTRAL] It is Monday, that's for sure, and I was up late watching that game, so I'm dragging around today.
[AGENT][NEUTRAL] Yeah, so on the COB it doesn't show that it was applied to the office visit. Now on her policy, office visits are not covered.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] No, I understand, but there's still 2 more codes.
[CUSTOMER][POSITIVE] That a payment was made. I don't know what you you guys are looking at, but it's detailed. The one that we submitted was detailed. It had allowed amounts. It had approved amounts and payment amounts.
[AGENT][NEUTRAL] Yeah, and
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, but it doesn't have anything applied to the deductible co-payer coinsurance because we're secondary, that's what we paid toward is the deductible co-payer coinsurance for the covered services. Now you're saying that $60 was toward the office visit. If the office visit was covered under her plan, then we could have applied benefits for that office visit, but her plan doesn't cover.
[CUSTOMER][NEUTRAL] But it says that she doesn't have office visit coverage, so I'm not following.
[AGENT][NEUTRAL] That's right. So her policy doesn't cover office visits, therefore, we can't pay the office visit copay.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] That's fine. So what I, I'm not worried about the visit. What about the other two codes that actually do have payments on them?
[AGENT][NEUTRAL] So this is
[CUSTOMER][NEUTRAL] That are that are that are not office visits, they're procedures so when she came in.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So we can't go by just the you know what I'm wondering if this was cut off.
[CUSTOMER][NEGATIVE] And something has to be because this it doesn't make sense. There's 3 codes, um.
[CUSTOMER][NEUTRAL] And again I understand the office is that this, but there's two codes that were paid.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Now, now on the bottom where it says member responsibility coinsurance 0, member responsibility deductible 0, and then it has the member responsibility co-pay of 60, we see that.
[AGENT][NEUTRAL] But it doesn't
[CUSTOMER][NEUTRAL] So yeah there's a whole top half of explanation of benefits. This is a detailed EOB.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But then you have the 99213 is from the service, the provider, the amount billed amount approved.
[CUSTOMER][NEUTRAL] And then what about the 11102 and 17,000 and that has a payment on it of $93 and.
[AGENT][NEUTRAL] It does have a payment.
[AGENT][NEUTRAL] OK, I see what you're saying. It does have a payment, but it doesn't tell us what was applied to the deductible co-pay or coinsurance for those CPTs.
[CUSTOMER][NEUTRAL] So how do, OK, so obviously the information that you guys received was not complete, so how do I get this to you again that will show that the payment was made and and I'm I'm assuming these other two procedure codes have some benefits attached to it.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Got you.
[AGENT][NEUTRAL] Yeah, it's, um,
[CUSTOMER][NEUTRAL] Outside of the office visit.
[AGENT][NEUTRAL] Let me check her benefits and let's just make sure. Yes, she does have the benefit for treatments and procedures in office.
[CUSTOMER][NEUTRAL] Mhm OK.
[AGENT][NEUTRAL] So we would need the EOB from Florida Blue.
[CUSTOMER][NEUTRAL] But see that's not how the there will be no EOB from Florida Blue because this is a for HMO plans. This is a business that handles all of the HMO plans for dermatology.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So it doesn't get processed through Florida Blue. I have no, there'd be nothing I could get from Florida Blue. Claims Development does all the processing for Blue Cross Blue Shield HMO plans for the state of Florida, specifically for dermatology.
[AGENT][NEUTRAL] OK, I'll tell you what, [PII], let me get you to one of our claims adjusters. Let's see what you're saying and let's see what they can.
[AGENT][NEUTRAL] Can use. Would that be OK?
[CUSTOMER][NEGATIVE] Yeah that'll be fine. I'm not trying to give you a hard time. I just don't understand what like I don't understand why this can't be processed so OK.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] No, no, no, I, I understand. Yeah, no.
[AGENT][NEUTRAL] No, I'm glad you keep asking. If you don't understand, ask. I'm not, I don't take it personally. We're just gonna get down to the bottom of it. How about that?
[CUSTOMER][POSITIVE] Yeah, definitely right.
[CUSTOMER][POSITIVE] That sounds fantastic. I appreciate your help today.
[AGENT][POSITIVE] All right. I hope you have a great day, [PII]. One moment please.
[CUSTOMER][POSITIVE] You as well thank you take care.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Good morning. Thank you for calling APL. This is [PII] speaking. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], how are you doing today?
[CUSTOMER][POSITIVE] I'm doing well [PII] thank you how are you?
[AGENT][POSITIVE] I'm doing all right for a Monday.
[CUSTOMER][NEUTRAL] Uh yeah
[AGENT][NEUTRAL] I have got a provider on the line. We've been going over and over, uh, around and around and in and out about an EOB and she's fine. She just doesn't understand and I've explained every way I can. It's on policy number 243.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got you.
[AGENT][NEUTRAL] 2958.
[AGENT][NEUTRAL] For [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I have [PII] on the line. Her callback number is [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] Um, it's regarding claim 3557918.
[AGENT][NEUTRAL] This is an EOB that she sent in on a prior request from a claim, and I keep telling her, you know, that the offices it's not covered. She's fine with that. The EOB shows a copay, but it doesn't even show what procedure the copays toward. And then she does have the office treatment writer. I keep trying to tell her we need a detailed EOB showing the deductible copay or co-insurance for each of those procedures, she says that.
[AGENT][NEUTRAL] I close up that image, the development, whatever it was, development, they process all the claims for HMO for Blue Cross, so she can't get she said there won't be an EOB from Blue Cross.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEGATIVE] And she doesn't know how to get what we need for those procedures.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] She just doesn't unders.
[AGENT][NEGATIVE] She says, I just don't understand. And I've tried, you know, from every angle, and I don't know.
[AGENT][NEUTRAL] If maybe you can
[AGENT][NEUTRAL] Maybe you're the magic touch today.
[CUSTOMER][NEUTRAL] Yeah, let's hope so. Is that her, um, you said [PII], right? OK, and it's dermatolog this dermatology it looks like associates or something, OK, and.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, dermatology Associates.
[CUSTOMER][NEUTRAL] I'm looking at it as well and I don't see.
[CUSTOMER][NEUTRAL] I can um I can try to talk to her. I'm not sure exactly what I can tell her either so I'm I'm looking for the copay line but I don't see it.
[AGENT][NEUTRAL] So that's what I was trying to tell her, even though they had the co-pay listed, it doesn't tell us what
[CUSTOMER][NEUTRAL] What which one it's directed for my guess is it's probably the office visit because that's usually um.
[AGENT][NEUTRAL] Procedure it was applied to, yeah.
[AGENT][NEUTRAL] That's, that's what she said.
[CUSTOMER][NEUTRAL] Because it doesn't say co-insurance and or deductible, it just says copay, so that's our office is a co-pay.
[AGENT][NEUTRAL] Yeah, but she's she keeps asking about those other two CPTs and how we can, what, what can she get.
[CUSTOMER][POSITIVE] So but I'll be happy to try to talk to her.
[AGENT][NEUTRAL] I just, I just don't know how to explain it any other way.
[CUSTOMER][POSITIVE] Exactly, right, got you.
[CUSTOMER][POSITIVE] I understand. I'll see what I can do.
[AGENT][POSITIVE] All right. Thank you, [PII]. Let me get her on the line. Have a good day.
[CUSTOMER][POSITIVE] You're welcome you too thank you.
[AGENT][POSITIVE] [PII], thank you for holding. I do have [PII] on the line and she's reviewing that claim and will assist you and you have a wonderful day.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] I appreciate it thank you so much have a good day.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Hi [PII], my name's [PII]. I'm in the claims department. How are you? Yes ma'am I'm doing well thank you how about yourself? Good, thank you. OK, so I have pulled up the um the claim information [PII] was explaining to me that um she had told you that uh the offices it's not covered under this plan and that um there were additional procedures that uh you were looking for reimbursement for however the explanation of benefits or payments that was received.
[CUSTOMER][NEUTRAL] Um, doesn't show us a co-insurance and or deductible, so this policy is limited, uh, supplemental benefit plan, so it would require, um, that coinsurance and or deductible amount to show under the coinsurance and deductible line as member, uh, you know, applied to the member's copay or deductible, I'm sorry, coinsurance now I do see the copay is $60.
[CUSTOMER][NEUTRAL] But that looks like um of course when it's when it says copay that's the office visit usually and then like I said if there's any coinsurance and or deductible due that would show on that line and then we would then uh you know.
[CUSTOMER][POSITIVE] Alright, yeah, that makes sense. So the way she was explaining it to me was not making sense to me. I'm like, what are you talking about? All right, well I appreciate your help. Thank you for looking into that for me and what was your name? My name is [PII], last initial [PII]. Perfect, uh huh and the reference number? You use my name in today's date.
[CUSTOMER][POSITIVE] All right [PII], alright, thank you very much for.