AccountId: 011433970860
ContactId: a7b44a66-8be8-4b58-9eeb-003d8b232ef2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 433299 ms
Total Talk Time (AGENT): 256494 ms
Total Talk Time (CUSTOMER): 119612 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/29/a7b44a66-8be8-4b58-9eeb-003d8b232ef2_20250129T13:55_UTC.wav
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[AGENT][NEUTRAL] Contacting ATL, my name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey, my name is [PII]. I'm calling from a provider's office. Um, I have a question about a claim for a patient of ours.
[AGENT][NEUTRAL] OK, I can certainly look up a claim. [PII]. What is that policy number that we're looking at today?
[CUSTOMER][NEUTRAL] Yeah, that policy number is 01628911.
[AGENT][NEUTRAL] Thank you, and the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][POSITIVE] I appreciate that. Is there a callback number I can have in the event that we're disconnected?
[CUSTOMER][NEUTRAL] Uh yes, my direct line is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you very much. I'm just looking at that now. And what date of service for [PII] are we looking at?
[CUSTOMER][NEUTRAL] We are looking at [PII].
[AGENT][NEUTRAL] OK, so we had an erupted tooth.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, removal on on [PII], is that correct?
[CUSTOMER][NEUTRAL] Mhm. That's right. Um, and we did receive a payment from you guys. However, the one line of the anesthesia was
[CUSTOMER][NEUTRAL] Denied, um, but the other one was covered, so, um, we didn't quite understand why that happened.
[AGENT][NEUTRAL] Sure, let's look at that.
[AGENT][NEGATIVE] We have a schedule of, of what is paid and what um what isn't and uh that's, I'm just looking that up right now to see what we have. OK, so the one that was, that was denied.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] 092-22.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So under the, the policy.
[AGENT][NEUTRAL] There are certain um services that are, there are certain things that are covered. And as far as this one goes, let me see if I can find it. There is a, uh, there is a type of anesthesia that is used.
[AGENT][NEUTRAL] I didn't, I do apologize, JJ. I'm just waiting for my uh.
[AGENT][NEUTRAL] The compute for the policy to pull up. Um, but, uh, 09222 is not covered under the policy. Now, uh, there is, there are certain types of anesthesia that are, um, this, this is not one of them. So let me see if I can find it here. It is finally pulled up. OK, so what, um, what is covered.
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Find it.
[AGENT][NEUTRAL] Uh 9110, that is covered, um.
[AGENT][NEUTRAL] See what else we have here.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] 9230.
[AGENT][NEUTRAL] 9,
[AGENT][NEUTRAL] 221 is covered 9220, um, but 9222 is not.
[CUSTOMER][NEUTRAL] So, normally if it's just a non-covered benefit that like I understand that the reason this one doesn't make sense to me is because 092-22 has to be billed as the first unit of anesthesia before the 09223 can be billed.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so those two, those two codes work together, so the fact that the 09223 is covered but not the 09222 doesn't really make sense because the 09223 can't.
[CUSTOMER][NEUTRAL] Even be billed without it, you know what I mean?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So what we can do is anytime we have something like this, it can always be reviewed again. And anytime we have something like this, you can send it in as an appeal and uh what we will do is we will review it uh with that in mind and if you don't mind letting us know that this is what.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You know, if you don't mind explaining that, uh, then what we can do is we can look at any way that we can that it can be paid. So if you will, um, uh, send that back to us, not necessarily the check, but if you will send us a request to have that particular CPT code, um.
[AGENT][NEUTRAL] Reviewed
[AGENT][POSITIVE] Then we will be more than glad to do that.
[CUSTOMER][NEUTRAL] OK, um, so what is the, what is your protocol for that? What do I need to do specifically?
[AGENT][NEUTRAL] OK, what we, the only thing that we would need to do, we need to reference, of course, the policy number, um, the claim number and the individual.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then you'll send in a written request for us to review that CPT code and just explain to us that that's in the billing process that you you bill one before the other um.
[AGENT][NEUTRAL] And then that that's the way that that you do it and then uh what we will do is we will review that.
[AGENT][NEUTRAL] Uh, to see if it can be paid, if it can be looked at again and and paid, and if it is if there's any way that they, that they can do that, that it does, it has to go to a higher authority rather than just one of our examiners. So what they will be doing is they will be reviewing that to see if it can be paid at all, but it's just a written request you need to refer to the, the policy number, the insured's number, and then that uh claim number and the CPT code that we are specifically looking at.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then just let us know that it is an appeal, you want us to review it, and we will certainly do that. Now, it usually takes 3 to 6 business days for that to be done. You'll then be sent an additional um uh explanation of benefits from us with the decision on it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, and then do I need to do that by mail? Are there any options, any other ways I can do that that might be faster?
[AGENT][NEUTRAL] Yes, you can, absolutely. Um, if you don't want to do it by mail, you can send it in by fax. Our fax number.
[CUSTOMER][POSITIVE] Awesome.
[AGENT][NEUTRAL] Um, it's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] 9423.
[AGENT][NEUTRAL] We will be more than glad to, to do that. Uh, once we receive it, um, uh, then, uh, they will begin looking at it, uh, to see what we can do about getting that, that paid or not. Um, but, uh, that, that's the procedure, that's the protocol for doing that. We actually have to have it written and send it back into us for review.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. All right, that I can do. Um, could I please get a call reference number? Oh yeah, go ahead.
[AGENT][NEUTRAL] Now, is this the only
[AGENT][NEUTRAL] Yes, um, yeah, my name is [PII]. The first letter of my last name is [PII]. We're gonna use that today's date as a reference. So [PII], is there any other claim that we need to look at?
[AGENT][NEUTRAL] Is this the only one that we have.
[CUSTOMER][NEUTRAL] Uh, no, that was the only one today, yeah.
[AGENT][NEUTRAL] OK, OK. Well, um, uh, we will be on the lookout for that. Uh we will uh send it in to, uh, to our supervisors for, for a review. We'll see what we can do about getting that covered.
[CUSTOMER][POSITIVE] OK, I appreciate your help.
[AGENT][POSITIVE] Thanks for contacting API have a good.