AccountId: 011433970860
ContactId: aa6b20a6-1fed-4e97-a3ab-2f034e483e47
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 804669 ms
Total Talk Time (AGENT): 268704 ms
Total Talk Time (CUSTOMER): 348601 ms
Interruptions: 3
Overall Sentiment: AGENT=-0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/aa6b20a6-1fed-4e97-a3ab-2f034e483e47_20250207T17:07_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hi, hi, excuse me. Hi, [PII]. This is [PII] calling from Austin ear nose and throat clinic, and I am calling to check status on a claim, please.
[AGENT][POSITIVE] I'd be happy to assist with the claim today, [PII], if I can get a good call back number for you.
[CUSTOMER][NEUTRAL] Sure, my direct line is [PII].
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] 01967205
[AGENT][NEUTRAL] Patient's name and date of birth.
[CUSTOMER][NEUTRAL] This is for uh [PII]. Her date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that information and what is the date of service?
[CUSTOMER][NEUTRAL] Service date in question is [PII] with a total charge of $280.
[AGENT][NEUTRAL] OK, I do show we did receive that claim, claim was denied because the physician's charges are not covered under the policy. Only procedures and treatment at an office visit are included or covered. Um, the co-pay associated with the physician's charges is not.
[CUSTOMER][NEUTRAL] OK, wait a minute, say that one more time. I am so sorry.
[AGENT][NEUTRAL] So the code that you billed for 99213, that's not covered under the policy. That, that's the physician's charges that you billed for and that's not covered. On treatment and procedures at the, I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] OK, the
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEGATIVE] Office visits are not covered.
[AGENT][NEUTRAL] I didn't say that. I said the physician's charges.
[AGENT][NEUTRAL] Which is the co-pay, which is associated with the co-pay that they have. Those are the physician's charges. That's not covered under the policy. Only treatment and procedures had you billed for a procedure that was done at that visit, that would have been covered, but that CPT code that you billed for the 99213 is not covered under the policy.
[CUSTOMER][NEUTRAL] OK, um, I'm.
[CUSTOMER][NEUTRAL] OK, so you're saying that the CPT 99213, right? It's not covered?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] So this, so that CPT that we build 99213 is an office visit.
[CUSTOMER][NEUTRAL] It's all the same, the 99213 in office, that's what it is. That's what that code is for is for an office visit, so you're saying that the member does not have office visit coverage or for their policy they don't have coverage for office visits.
[AGENT][NEGATIVE] OK, I don't want.
[AGENT][NEGATIVE] I don't want it to be relayed back to the customer just blanket office visit because they'll think nothing at the visit is covered. I just want them to understand or I want you to understand when you explain to them why the claim denied that it's the co-pay associated with the physician's charges for the office visit that's not covered, but any treatment and procedures at that visit is covered.
[CUSTOMER][NEUTRAL] I think I'm
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But I understand what you're saying. You're saying 99213, when you look it up, it says office visit and, but when you say that to the customer, well, it did not because office visits aren't covered, then they call us and be like, I have office visit coverage but they have treatment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] At the visit that's covered.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Treatment and procedures.
[CUSTOMER][NEUTRAL] OK. All right. Um.
[AGENT][NEGATIVE] So had you sent this and it had the 99213 and then it had, I'm not sure what's one of your most popular CPT codes for treatment, but it had the doctor did something and you bill for that, or they did a test, you know, anything that was done and performed at the visit, we would have covered and then we would have denied that. But that was the only thing that you billed for, so it was denied.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I think uh, uh, it's starting to make more sense. I'm, uh, uh, I had got quiet because I was looking at the, uh, the, the medical notes.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, like this is what, ear, nose, and throat, so.
[CUSTOMER][NEUTRAL] OK, so there, so, so it's just got, yeah, so it's gotta be like a treatment code, not uh just a diagnosis code that we're billing for, OK.
[AGENT][NEUTRAL] uh, not diagnosis code, but you mean the office visit or the physician's charges procedure code.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Yeah, the uh the, we saw the, the, the patient on this office visit and we have two diagnosis that the doctor diagnosed the member with.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But the doctor didn't necessarily treat the patient with the diagnosis that he was diagnosed with. So, in other words, you're saying that
[CUSTOMER][NEUTRAL] It has to be some sort of treatment that the doctor provided to the member in order for this charge to be covered. Am I understanding that right?
[AGENT][NEGATIVE] Not for, no, no, not for the 99213 or however you bill it because I know it's multiple ways 99204 99. I know there's multiple charges for the physician's charge. It doesn't matter whether something's done or not, it's still not gonna be covered. What I'm saying is let's say.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You perform, what's one of your most popular procedures at the visit?
[CUSTOMER][NEUTRAL] Mm, uh, I will say an audio charge for 9 which is CPT code it's uh 92557, so that's like uh.
[CUSTOMER][NEUTRAL] It's an audio charge. One of our audiologists would it's just put the uh do the audio test on the patient.
[AGENT][NEUTRAL] OK. So, had, had you sent, I'm sorry, had you sent in this claim with the 99213 and the 92557.
[CUSTOMER][NEUTRAL] So that is a
[CUSTOMER][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEGATIVE] We would have done the same thing. 99213 denied, that's not covered. 92557, we would have paid.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] So only treatment and procedures at the visit is covered. The co-pay that's associated with the physician's charges are not.
[CUSTOMER][NEUTRAL] OK, got it. All right. um.
[CUSTOMER][NEUTRAL] Let's see here let me make sure I'm looking at this other information here.
[CUSTOMER][NEUTRAL] Hold on one second.
[CUSTOMER][NEUTRAL] OK, [PII], can we, um,
[CUSTOMER][NEUTRAL] We didn't get the explanation of benefits um on this data service from you all. Is there any way that you can send out another one? Can you either fax it or email it?
[AGENT][NEUTRAL] Sure, we can fax it. One moment.
[CUSTOMER][NEUTRAL] Just you can uh make it out to uh make it attention [PII], so I mean our apartment is pretty big so they'll know who to give that information to when it comes through.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, what is that fax number?
[CUSTOMER][NEUTRAL] It is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, so that's [PII].
[CUSTOMER][POSITIVE] That's correct. Attention [PII].
[AGENT][NEUTRAL] All right. You should receive that within the next, maybe about 7 to 10 minutes.
[CUSTOMER][NEUTRAL] OK, thank you and I, I really, really, really wasn't trying to be difficult. It was throwing me off because I was looking at the um the explanation of benefits, uh.
[CUSTOMER][NEGATIVE] For a previous date on the same member and on there it has under the remark codes office visits are not covered by the above numbered policy so that's why I was saying that because I'm I'm looking at the EOB for another day and it just confused me because this is exactly what the EOB says on a previous uh service date, um, [PII] to be exact.
[AGENT][NEUTRAL] But do they have the, do they have the writer?
[AGENT][NEUTRAL] Do, do they have the same exact policy because the only reason the treatment she has um uh benefits for treatment in the office is because she add a rider to her policy.
[AGENT][NEUTRAL] So, sometimes you, you know, it, it just depends.
[CUSTOMER][NEUTRAL] Yeah, yeah. I mean, I, I'm, I'm looking at it because I see this one is just the offices and then we have the audio charges on here and it shows, uh, I see where you're, you're, uh, you, you were saying the treatment physician office and it has on the EOB treatment physician office and those two codes, let me see, did they pay something on these?
[CUSTOMER][NEUTRAL] Um, let me check.
[CUSTOMER][NEUTRAL] See if they paid.
[CUSTOMER][NEGATIVE] Um, didn't look like they paid anything.
[AGENT][NEUTRAL] Did they give a reason why was their benefits maxed out or?
[AGENT][NEUTRAL] If you give me the claim number I can pull it up.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Sure, uh, I see it on here now. I have a claim number is.
[CUSTOMER][NEUTRAL] 3533282 and it I see here now it says that your primary insurance provided full benefits therefore there are no benefits payable.
[AGENT][NEGATIVE] OK, so that's what happened. There was nothing for us to pay.
[CUSTOMER][NEUTRAL] So that's why nothing was paid. OK, got it.
[AGENT][NEUTRAL] But it would have had they assigned patient responsibility, we would have paid the 92557 and the 92,550.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][POSITIVE] All right, Ms. [PII], thank you for that education there.
[AGENT][NEGATIVE] OK, I just didn't want to get back to Ms. [PII]. You don't have office business coverage, and she used to be calling us. What do you mean?
[CUSTOMER][NEUTRAL] Is it
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] No problem at all, and I think she's aware because it looks like she uh she, she paid for her.
[CUSTOMER][POSITIVE] Uh, looks like it was like $80 for the [PII], so she's good on that.
[CUSTOMER][NEUTRAL] OK. Um, so,
[CUSTOMER][NEUTRAL] With it not being covered for the 7110, would that be patient responsibility then?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][POSITIVE] Alrighty, you got it. I'll wait to get that EOB and posted. Thank you so much, [PII]. Is there a call reference number?
[AGENT][NEUTRAL] Um, reference is just my name and today's date and time.
[CUSTOMER][NEUTRAL] OK, first initial of your last name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] All right, and so with it being patient responsibility.
[CUSTOMER][NEUTRAL] Uh, I guess we can apply it as the uh.
[CUSTOMER][POSITIVE] OK, I'll wait to get that EOB. All right, thank you, [PII]. Have a great rest of your day.
[AGENT][POSITIVE] OK, thank you for calling [PII]. Have a good day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Mhm. Bye-bye.