AccountId: 011433970860
ContactId: b798ee49-958f-407e-bea9-480c74ce1e56
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 592619 ms
Total Talk Time (AGENT): 134612 ms
Total Talk Time (CUSTOMER): 184866 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/02/b798ee49-958f-407e-bea9-480c74ce1e56_20250502T14:38_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII]. I'm calling for a 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 purpose. I already have the UBN. I want more clarification about the denial.
[AGENT][NEUTRAL] OK, [PII], I can help you with the claim status. um, can I please get your callback number just in case the call is disconnected?
[CUSTOMER][NEUTRAL] It is a direct line, [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And then what is the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] It is [PII], [PII].
[CUSTOMER][NEUTRAL] And the policy number is
[CUSTOMER][NEUTRAL] Yes, one moment.
[CUSTOMER][NEUTRAL] 02512588.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK, let me look up that policy real quick.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, and then, um, may I have the date of service?
[CUSTOMER][NEUTRAL] Mm, it is on [PII].
[AGENT][NEUTRAL] And the charge amount please?
[CUSTOMER][NEUTRAL] One moment. Just doing cross verification for the bill amount.
[AGENT][POSITIVE] Yes ma'am go ahead and take your time.
[CUSTOMER][NEUTRAL] $170 170 dollars even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is the charge amount after the primary insurance paid their part?
[CUSTOMER][NEUTRAL] One moment. The bill amount, the one which we have billed the claim.
[CUSTOMER][NEUTRAL] pulling up the information.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] The bill amount is $170 even.
[AGENT][NEUTRAL] Oh, OK, and then what is the name of the facility?
[CUSTOMER][NEUTRAL] It is
[CUSTOMER][POSITIVE] Please yeah.
[CUSTOMER][NEUTRAL] Medical Group LLC.
[AGENT][NEUTRAL] OK and you said that the claim?
[CUSTOMER][NEUTRAL] Could you spell it with your name?
[AGENT][NEUTRAL] You said the claim had already been process can you please give me the claim number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The claim number is
[CUSTOMER][NEUTRAL] 35
[CUSTOMER][NEUTRAL] 88
[CUSTOMER][NEUTRAL] 58
[CUSTOMER][NEUTRAL] 4.
[AGENT][NEUTRAL] OK, I'm gonna put you on a brief hold while I look up this claim and I'll be right back with you.
[CUSTOMER][NEUTRAL] And could you spell it again for me for documentation purpose?
[AGENT][NEUTRAL] Yes, it's [PII]
[CUSTOMER][NEUTRAL] And uh the denial reason stating here is
[CUSTOMER][NEUTRAL] One moment. It is stating here as offices that are not covered by above number policy.
[CUSTOMER][NEUTRAL] Good is leading to the process and also patient counter for edema entry to the physician in the office or outpatient visit for the evaluation management to the patient. So 99213 is getting denied and also getting to the process.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. All right. I'm a.
[CUSTOMER][POSITIVE] Yes, please take your time now.
[AGENT][NEUTRAL] Yes, it's gonna be a brief hold while I look up the claim. I'll be right back with you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding for me. So I do have the claim and you are correct, the claim has been denied because office visits are not covered under the patient's policy.
[CUSTOMER][NEGATIVE] It is denied because of, uh, it is not covered.
[CUSTOMER][POSITIVE] And the member plan, correct.
[AGENT][NEUTRAL] Right, noncovered.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And it is not pay, correct?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] It's non covered under the patient's plan.
[CUSTOMER][NEUTRAL] Uh, then he pays the check.
[AGENT][NEUTRAL] I'm sorry, can you repeat the question?
[CUSTOMER][NEUTRAL] Are there any specific guidelines? Do you have any other code or any article number that you wanted to suggest us?
[AGENT][NEUTRAL] No, just it's non covered under the patient's plan.
[CUSTOMER][POSITIVE] Mhm. OK, thank you so much. And uh
[CUSTOMER][NEUTRAL] I do have a opinion and also of the same mailing address only for documentation purpose. I just wanted to verify the same at the.
[AGENT][NEUTRAL] OK, you want to know the appeal process, is that correct?
[CUSTOMER][NEUTRAL] I do have a bill and also correct the same mailing address. Only for documentation purpose, I wanted to verify the same.
[CUSTOMER][NEUTRAL] The address.
[AGENT][NEUTRAL] OK, appeal must be sent within 180 days from the day the claim is initially processed and you need to send the letter while you're appealing, and it goes to [PII].
[AGENT][NEUTRAL] That's in [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] Updating the same one moment.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII]. OK. And corrected claim and mailing address will remain the same, correct?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] Timely filing for the collected claim is also 180 days from the process date, correct?
[AGENT][NEUTRAL] Yes, that's correct, no.
[AGENT][NEUTRAL] And correction
[AGENT][NEUTRAL] There is no time limit, but you also send the letter why it needs to be corrected.
[CUSTOMER][NEUTRAL] OK, so correct the same time you filing, there is none. Correct and it is 180 days, correct?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. And uh attention to claim to appeal and there's no specific form for appeal, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] May I know the call reference number, please?
[AGENT][NEUTRAL] Yes ma'am, you can use my name [PII] and today's date.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much for helping me. You have really helped me a lot. I really appreciate it.
[AGENT][POSITIVE] You're very welcome, Miss [PII]. Is there anything else I can help you with before we go?
[CUSTOMER][POSITIVE] No, you have really helped me a lot. Thank you so much.
[AGENT][POSITIVE] You're welcome. You have a wonderful weekend and thank you for calling APL.
[AGENT][NEUTRAL] Bye-bye, ma'am.
[CUSTOMER][POSITIVE] Thank you. Bye.