AccountId: 011433970860
ContactId: b6394ba4-e270-4bf9-8790-35124a999459
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1422979 ms
Total Talk Time (AGENT): 481833 ms
Total Talk Time (CUSTOMER): 333392 ms
Interruptions: 5
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/10/b6394ba4-e270-4bf9-8790-35124a999459_20250310T14:30_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I'm calling from a provider's office regarding claims.
[AGENT][NEUTRAL] OK, well I can help you with your claims and may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's [PII] phone number [PII].
[AGENT][NEUTRAL] Thank you for that. And [PII], and may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, that is 01994047 and then ML 8.
[CUSTOMER][NEUTRAL] Make sure, um.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, it is [PII] [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 date of service for the claim you'd like me to check on?
[CUSTOMER][NEUTRAL] Yes, it is [PII].
[AGENT][NEUTRAL] Alright, and the total bills?
[CUSTOMER][NEUTRAL] That was, let me just see what we sent to you guys. Give me one second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 991.
[AGENT][NEUTRAL] All right, hold on one moment.
[AGENT][NEUTRAL] And [PII], is it alright if I place you on just a brief hold while I locate the claim for you?
[CUSTOMER][NEUTRAL] That is fine.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] That's not the same provider.
[AGENT][NEUTRAL] 7884.
[AGENT][NEUTRAL] What?
[AGENT][NEUTRAL] Alright, I'm gonna have to ask her if it the tax ID, but do any of these have a 991.
[AGENT][NEGATIVE] Cause it's not, it's just not on file.
[AGENT][NEUTRAL] This is a different provider. Whoa, hold on.
[AGENT][NEUTRAL] OK, I need the tax ID.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. May I have the tax ID?
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Alright, thank you. It was coming up ENT and allergy and I was looking for Prisma Health, so I wasn't sure if it was the right thing, but thank you.
[CUSTOMER][NEUTRAL] No, we are, we are ENT y, yeah, we are NT.
[AGENT][NEUTRAL] OK. So, um, we received the claim on [PII].
[CUSTOMER][NEUTRAL] And that's the first time?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Got it OK.
[AGENT][NEUTRAL] Well, actually, I'm sorry, hold on, because the other one, I'm still thinking about the EMT. Hold on.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] The first time we received it was [PII].
[CUSTOMER][NEUTRAL] Gotcha. OK.
[CUSTOMER][NEUTRAL] So much of 23 and do you know how it processed that first time?
[AGENT][NEUTRAL] Yes, let me see.
[AGENT][NEUTRAL] It was denied because insured's primary insurance provided full benefits.
[CUSTOMER][NEUTRAL] Got you, so did you guys receive the primary EOB?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Because it looks like they applied a $50 copay.
[CUSTOMER][NEUTRAL] From primary, um.
[CUSTOMER][NEUTRAL] We received a letter stating that office visits are not covered under the policy, is that true?
[AGENT][NEGATIVE] Right, so that was the 2nd, um, that was the denial reason for the 2nd time we received it this month or last month, sorry.
[CUSTOMER][NEUTRAL] OK, but the amount that's applied, it's not applied to the office visit, it's applied to the diagnostic code.
[CUSTOMER][NEUTRAL] Is there any way it would still be processed now?
[AGENT][NEUTRAL] So, hold on one moment. Let me pull up the um the full benefits so I can see how it's broken down. But if so primary has its own benefits and secondary, our insurance has its own benefits. So if the office visits aren't covered, then even if it is a co-pay, we still wouldn't apply because it's not a covered charge. But let me double check.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That the only, the only reason why I asked is they applied the copay not to the office visit. They applied it to the other code. That's why I was seeing if it's possible that it could still be covered.
[CUSTOMER][NEUTRAL] But no matter what's done in the office, it wouldn't be covered period is what you're saying is what I think you're saying.
[AGENT][NEUTRAL] Let me
[AGENT][NEUTRAL] Right, let me see what this, well, let me first pull up the benefits and then I'm gonna see what this code is, because there's only one code on this claim, but let me, I can look at the second one and see too if it's.
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] More than one code on that one. Hold on one moment.
[CUSTOMER][NEUTRAL] And then this was sent on.
[AGENT][NEUTRAL] OK, I see what you're saying. So the first claim that came in only had code 31231, which is why that came back as the primary uh provided full benefits. But then on the one from February, that has the 99214 and
[CUSTOMER][NEUTRAL] 231.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEGATIVE] To code and that's why I denied that way. Got you. Um, let me just see something because they applied the co-pay. I just wanna see where they applied it to. Yeah, they apply the copay, mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Well, you sound, you
[AGENT][NEUTRAL] You talking to me or you thinking? Because it was, it sounds really far away, so I didn't know if you if you were thinking it through her.
[CUSTOMER][NEUTRAL] A little bit of both, a little bit of both.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But OK, so now I do see that it applied to the 31231.
[CUSTOMER][NEGATIVE] It did not apply to the office visit. Now my question is, you does their secondary just not cover anything done in the office outpatient.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So for the outpatient benefits, hold on, let me go back.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, so it's $5000 per calendar year. There's no like, OK, so there's no in-office coverage for the
[AGENT][NEUTRAL] Place of service code, but they have the office treatment rider, which could cover the treatment in the office.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, so then that would bring it back to my question is they applied the copay to the other code, is there any way that that could be reprocessed because it didn't apply to the actual office visit code.
[AGENT][NEUTRAL] OK, hold on one moment tonight is duplicate. What was the duplicate?
[AGENT][NEGATIVE] So it wasn't denied because we can't pay for it. It was denied because the EOB showed that primary paid.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] In full.
[AGENT][NEUTRAL] But you're asking about the copay. Hold on.
[CUSTOMER][NEUTRAL] And then what is it
[CUSTOMER][NEUTRAL] Yeah, because if you open up the EOB, they applied a $50 co-pay. That's why I'm sure if you guys didn't see that and if we are still within time for that the reprocessed.
[AGENT][NEUTRAL] Well, you're definitely in time because we don't have a timely filing, so let me, um, I'm waiting for the, the documents that were submitted to populate.
[CUSTOMER][POSITIVE] Oh perfect.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] You might have to submit what you have there because from what was sent over, it doesn't even have a column for co-pays. It just shows um the
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEGATIVE] It doesn't have a column. If you look at the bottom, it says PR 350.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Like it says reason codes and then it says a CO 45 377 12 and then the patient responsibility 350 so there isn't a column for that, but let me see if I can get you the actual Cigna ELB that's ours.
[AGENT][NEUTRAL] Well, no, no, no, let me reach out to claims and see um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] How they would handle that. Do you mind if I place you on a brief hold?
[CUSTOMER][NEUTRAL] Yes, that's fine.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What are we supposed to do now?
[AGENT][NEUTRAL] But it's not a cover, I mean, it's not that it's not a covered charge.
[AGENT][NEUTRAL] The EOB just showed that primary paid the full benefits, but she's asking for reimbursement of the
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, hold on.
[AGENT][NEUTRAL] Oh God.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] That's yeah.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Wait,
[AGENT][NEUTRAL] But that wouldn't go to that.
[AGENT][POSITIVE] Whoa, whoa, whoa, whoa, whoa, whoa, whoa.
[AGENT][NEUTRAL] That would be for the patient.
[AGENT][NEUTRAL] Hold up.
[AGENT][NEUTRAL] Uh, see, this is why you need to be able to call somebody.
[AGENT][NEUTRAL] Because this is a quick que.
[AGENT][NEGATIVE] I'm not doing that. uh, I want to follow the rules, but this makes no sense.
[AGENT][POSITIVE] I can just call and ask a question and help this lady.
[AGENT][NEUTRAL] Provider wants to know even if full benefits are paid, can they
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Isn't that what she said? Let me make sure.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes, I'm here.
[AGENT][POSITIVE] Hey, thank you so much for holding. I'm just checking on you. I'm still here with you. I'm speaking with my um team leading claims, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No problem. OK.
[AGENT][NEUTRAL] All right. Hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I'm about to call.
[AGENT][NEUTRAL] Is this Metlink? What kind of policy is this? I forgot already. Oh yes, Metlink.
[AGENT][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] [PII], hey girl. I'm sorry, it's [PII]. I wasn't expecting to hear you.
[CUSTOMER][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] How are you?
[AGENT][NEUTRAL] How are you?
[CUSTOMER][POSITIVE] I'm good. How are you today?
[AGENT][NEUTRAL] I'm good. OK. I just have a quick question.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you want the policy number or you want me to just add?
[CUSTOMER][NEUTRAL] Um, the policy number, please. Thank you.
[AGENT][NEUTRAL] OK, you're welcome. It's 1994047.
[CUSTOMER][NEUTRAL] OK, I have the Esteler. OK. Yes, ma'am.
[AGENT][NEUTRAL] Yes, so it's claim 356.
[AGENT][NEUTRAL] 842 5.
[CUSTOMER][NEUTRAL] OK, so the last claim.
[CUSTOMER][NEUTRAL] OK, yes, I show that I'm sorry, go ahead, sweetheart, sorry, sorry.
[AGENT][NEUTRAL] So, so they're asking about the um code 31231. Even though primary has paid the full benefits, they're saying there was a $50 co-pay, we still pay towards the the co-pay.
[CUSTOMER][NEUTRAL] OK, one moment please. OK, so that's OTR. So there is a fee for OT there's a benefit for OTR. So give me one second and I'm so sorry. It shows that that was a duplicate. Let me see when the last time there's a duplicate 312 13. I'm just talking to myself. Thanks. OK.
[AGENT][NEUTRAL] It's OK because I, I was thinking it through too, because at first I'm like, well no because office visits aren't covered, but she's not asking about 99214, she's asking about the other codes. I was like, hm, wait a minute, I don't know.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, I see 312 31. It denies a duplicate and it denies a duplicate because it shows that the major medical.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, I gave you the dup, yes, but the reason, OK, so the the it was denied because primary paid everything.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] So if, so they're asking me if primary pays everything, do they still get the reimbursement for the co-pay, and I don't know. I, I didn't know.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Alrighty.
[CUSTOMER][POSITIVE] It's good talking to you.
[AGENT][NEUTRAL] That's all I needed.
[AGENT][POSITIVE] Thank you. All right, bye-bye.
[CUSTOMER][POSITIVE] You're welcome bye bye bye.
[AGENT][NEUTRAL] She right now.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes, I'm here mhm.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. So, um, no, the co-pay is not reimbursed if we don't apply to the since we didn't apply anything to the claim, we can't reimburse the co-pay because primary pays for everything.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But they didn't though that's why I'm confused.
[CUSTOMER][NEGATIVE] Like if they didn't process with a $50 copay for the EOB, why are you guys still stating that they did, they process it in full.
[AGENT][NEUTRAL] Because the co-pay is the patient's responsibility, so that means that's what the patient has to pay. What insurance
[CUSTOMER][NEUTRAL] Got you, so you guys don't cover copays.
[AGENT][NEUTRAL] We do cover co-pays, deductibles and co-insurance after primary. So if primary paid everything, there's nothing for us to apply, so we, we couldn't apply to this claim.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] Understandable. That's why I'm saying maybe I can send you guys in the EOB because they applied a $50 copay to the claim.
[CUSTOMER][NEUTRAL] That's why I'm a little bit confused.
[CUSTOMER][NEGATIVE] I don't know just because there's not a copay line that you guys are not reading that, but they did apply something they did not pay in full.
[AGENT][NEUTRAL] OK, so,
[AGENT][NEUTRAL] OK, so the $50 co-pay is not for the insurance company to pay, it's for the insured.
[AGENT][NEUTRAL] So outside of the $50 copay, primary, all the charges, primary pay covered everything outside of the $50. So since we're second to primary, there was nothing outside of the $50. There was nothing left over for us to pay because primary paid everything. So we did not apply to this claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][POSITIVE] Understandable.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But that
[CUSTOMER][NEUTRAL] That's why I'm a little bit confused because normally speaking if primary covers the claim and they apply a $50 copay to the claim, secondary then picks it up because you said that you guys cover copays and deductibles.
[CUSTOMER][NEGATIVE] So that's where the disconnect is. I don't understand why you wouldn't pay that.
[AGENT][NEUTRAL] So if, so if there was
[AGENT][NEUTRAL] Right, so if there was like $20 left over, charges and a co-pay.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Then we would have taken care of that $20 and could reimburse for that co-pay. But since there was nothing for us to apply, we did, we did, we didn't apply to the whole claim.
[AGENT][NEUTRAL] But if you would like to submit the EOB for more processing, you definitely can and we can repro you know, process what you send in.
[CUSTOMER][NEUTRAL] That's weird.
[CUSTOMER][NEUTRAL] OK, I'll I'll go ahead and do that then.
[AGENT][NEUTRAL] OK. Well, I'll go ahead and note the policy for you and then once we receive it, we'll go ahead and process it for you.
[CUSTOMER][NEUTRAL] I'll go ahead and
[CUSTOMER][POSITIVE] OK perfect thank you.
[AGENT][POSITIVE] You're very welcome. Well, thanks for calling APL. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No, that was all.
[AGENT][POSITIVE] All right, well, I hope you have a great day.
[CUSTOMER][NEUTRAL] You as well bye bye.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][POSITIVE] Oh, go ahead. I thank you very much.