AccountId: 011433970860
ContactId: b947b23b-9ed6-4ebe-9737-69dacf41627a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1521079 ms
Total Talk Time (AGENT): 958188 ms
Total Talk Time (CUSTOMER): 603500 ms
Interruptions: 15
Overall Sentiment: AGENT=0.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/21/b947b23b-9ed6-4ebe-9737-69dacf41627a_20250521T21:18_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] with the care team. I have a Miss [PII] on the line. She's needing a deeper dive into her claim and I can help her with. Um, a lot of it was denied, and she said she only got $50 paid. She's also not seeing that $50 in her bank, but she has some questions about the denials when she said that she had turned everything in. So I was wondering if you could help her.
[AGENT][NEUTRAL] I can try, sir. What's the policy number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 25
[CUSTOMER][NEUTRAL] 31373
[AGENT][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] And she's been verified and her name is [PII]. It's, it's all the same claim, so it's a little confusing to me too, um.
[CUSTOMER][NEGATIVE] But I did see that there are some denials. I did see.
[CUSTOMER][NEUTRAL] Some of the itemized bills and so she has questions about.
[CUSTOMER][NEUTRAL] What else she needs done even though I read the denial codes to her.
[AGENT][NEUTRAL] OK, and that's the 3602591, right?
[AGENT][NEUTRAL] For herself, yep, OK.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK, you can uh.
[CUSTOMER][NEUTRAL] And what was your name again?
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] Oh hi, I've transferred to you before.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. You can go ahead and.
[CUSTOMER][POSITIVE] Alright, thank you so much. I will say I'm gonna give you a heads up she's upset.
[AGENT][NEUTRAL] Oh boy, OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] All right, one moment.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] [PII], are you still there? I am. I have a Miss [PII] on the line. She can help you with your claim support, OK.
[CUSTOMER][POSITIVE] OK, thank you so much thank you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Hi Ms. [PII]. My name is [PII]. Can you hear me OK? Hi.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hi.
[CUSTOMER][POSITIVE] Yes, yes, thank you.
[AGENT][NEUTRAL] OK, alright, so, um, [PII] transferred you over to me we needed to kind of go over your claim a little bit deeper and see exactly what's going on so I understand um there's some additional information that we're requesting for your claim um and there was also some services that were not covered.
[CUSTOMER][NEUTRAL] Yeah, they didn't tell me that they were requesting.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Sorry.
[CUSTOMER][NEGATIVE] Uh, they didn't tell me that they were requesting anything. I just happened to, well, they sent a text saying that it was completed for me to look at it, so I got home and signed in and I'm seeing that it says that the benefits paid and then I go, well, it's not in my account so that's the first thing.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEGATIVE] And then it's showing that it was only satisfied for the first occurring benefit.
[CUSTOMER][NEUTRAL] With an additional $50 for testing and I go all those claims that I sent the only payout was $50.
[AGENT][NEUTRAL] OK, well I'm showing actually the payout was for the um.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] There was a $5000 benefit for the um.
[AGENT][NEUTRAL] Initial cancer uh benefit.
[CUSTOMER][MIXED] Yeah, right, that's what I'm saying that was satisfying, but outside of that it was only a $50 payment that was for diagnostic testing.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right, um, exactly, so what they did is they went ahead and converted that over to a preventative service that was payable under your plan for the screening, so they included that $50 benefit there. Now, um, there is some additional information that's being requested that's needed, um, for the claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Um, is for the surgery, they're asking for a fully itemized surgery bill that includes
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I didn't have, no, see, this is where it's wrong. I haven't had the surgery yet. I've had the MRI.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And I sent that, so you guys are not gonna assist with the MRI?
[CUSTOMER][NEGATIVE] So I don't see nothing for that. I don't see anything for the biopsy. The biopsy is the one that you guys are probably confusing the two. He did not use, he did not put me to sleep. He's dead in the area.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, again, for that, they do put it as a surgery, not to interrupt you, but for that biopsy, they consider it under the surgical benefit because that's what it, you know, that biopsy is essentially. So what we're needing is that itemization that includes that procedure code and, you know, the diagnosis code. Usually, you can obtain that from the um the surgeon who performed the biopsy. So like I said, that's considered under that um surgical benefit. So,
[CUSTOMER][NEUTRAL] So, mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, so that's the one that I sent on [PII], so you need more information for that.
[AGENT][NEUTRAL] Yes, and like I said, I'm in the process. So now I do see the pathology report. I'm in the process of looking up each uh each individual uh claim, the claim information that was submitted. So, so, um, like I said, the surgery and anesthesia, like I said, that would be the biopsy and the anesthesia for that. We're needing that, um.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Itemization so now I'm gonna look at the next one.
[CUSTOMER][NEUTRAL] OK, so I'll follow up with that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now I'm looking at the um information that was submitted on the [PII]. Now as far as the um benefit.
[CUSTOMER][NEUTRAL] Yeah, that is the one on there mhm.
[AGENT][NEUTRAL] Yeah, as far as your benefits, um, you said they weren't in your account just yet?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mm mm.
[AGENT][NEUTRAL] OK, so the claim was finalized on yesterday's date, so it usually takes up to 1 to 3 business days for it to um deposit into your account. Yeah, so, um, if you don't see that by say uh let's see, Wednesday, if you don't see it by Friday, which you should, um, you can, you know, alert us at that point, but you should receive it um like I said it's usually it's sometimes the next day it really just depends on your banking institution.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, that makes sense.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, um, some of them are a little bit quicker and posting it sometimes you'll see it as a pending transaction. It just depends on your banking account.
[CUSTOMER][POSITIVE] Yeah, you're right.
[CUSTOMER][NEUTRAL] OK, OK, that makes sense. She couldn't tell me that. I was just like, it's not there. I, I, uh, was calling because my husband's check is gonna hit tonight and I was like, well, let me call, you know, when we need to start paying our bills. I was like, well, that's not in there either.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, understood.
[AGENT][NEUTRAL] Yeah, understood.
[CUSTOMER][NEUTRAL] So that's how I know, yeah.
[AGENT][NEUTRAL] No, so yeah, so hopefully like I said it'll show up, um, you know, tomorrow or like I said at the latest Friday it's usually it's usually not more than unless there's some kind of problem that we don't know about yet. I mean that does happen sometimes when we send a file to the bank, something could be wrong with it. It does happen occasionally, not it's not a normal practice though so that's why we usually say 1 to 3 business days you should see that uh transaction, OK?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And now, um, what I'm looking at on the um the information submitted on the [PII] that was that data service the [PII] which again is that um.
[AGENT][NEUTRAL] Look at that procedure, that biopsy procedure. So we're needing that, um, again, that itemization. And then um as far as the imaging, let's take a look at that one. Just bear with me for one moment cause I think.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so I'll call that's, yeah, on the [PII] that's on the biopsy, so I'll call them and get.
[AGENT][NEUTRAL] And it looks like for the imaging we're asking for an itemized bill for that as well. Now I'm gonna pull that up, just bear with me for one because it looks like they're asking for a procedure code. I'm gonna pull that up. Just bear with me for one moment. It just takes a second. I have to go into each one individually, so it takes a little bit more time so, OK.
[CUSTOMER][NEUTRAL] Get uh item of myself from them.
[CUSTOMER][NEUTRAL] I don't know
[CUSTOMER][NEUTRAL] What do you mean imaging?
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] No, you're fine.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I just wanna make sure I'm looking at everything so.
[CUSTOMER][POSITIVE] No, you're fine. I mean it's very helpful.
[CUSTOMER][NEGATIVE] So that might be, I don't know, damaging.
[AGENT][NEUTRAL] And that looks like it was on [PII]. And there's a procedure that was listed there and it looks like
[AGENT][NEUTRAL] We're asking again, we're asking.
[CUSTOMER][NEUTRAL] The 5410, that's the MRI.
[AGENT][NEUTRAL] Yes, and we're needing the code for that because there isn't uh there isn't a procedure code so we're asking for a procedure code for that particular uh MRI.
[CUSTOMER][NEUTRAL] The MRI.
[AGENT][NEUTRAL] That was done on [PII].
[CUSTOMER][NEUTRAL] Wow, so it's not on there with all with all that jumbo. They have uh C 8908, that's not a code?
[AGENT][NEUTRAL] It's no it's not now with that it could be their internal coding, but usually that MRI is gonna it I believe the code starts with like a 7 it's a CPT code it's 5 digits, but that CPT code, it's that's what we call that that procedure code, um, that code is not listed there, so that's why we're asking for the actual procedure code.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And again that should be able to be obtained uh at the facility where you have the um imaging done at they should be able to provide you and like I said, what it's gonna consist of is an itemization itemized bill and usually you'll just tell them you need an itemized bill with uh diagnosis and procedure codes and usually they should be able to provide that for you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And now
[CUSTOMER][NEUTRAL] I'll get both of those.
[AGENT][NEUTRAL] And I'm looking at the last piece, so just bear with me.
[AGENT][NEUTRAL] While I pulled this one up.
[CUSTOMER][NEUTRAL] So you need coding you need itemized bills on those two, OK, and then this last one is supposed to be itemized bill.
[AGENT][NEUTRAL] Right and and that's what I'm looking at now is that itemization. however, if you do you have that copy of that paper in front of you?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so under under there's a revenue code and then there's a revenue code description, but it doesn't give us the actual code so those next two sections that's the build code and the build modifier, the build code would be the procedure code and there's nothing there and the modifier usually sometimes they use different modifiers and this would be from their like billing department um it it gives us the actual procedure code which would be that build code and that would really be under um on on both the.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, lines number 7 where the OR services are and then number 8 where the diagnostic mammogram that would give us again that actual procedure code because they didn't list it there they just gave a description the revenue codes are basically what the hospital uses like their internal billing, um, what they use.
[AGENT][NEUTRAL] But the actual procedure code is the, you know, service that was done. Like I said, for that um OR service there would be a CPT code for the type of surgery or if it's biopsy or whatever it is they'll give us the actual code and the same thing goes for that um revenue code, the 401, the diagnostic mammogram. They did not provide a CPT code for that either.
[CUSTOMER][NEUTRAL] OK, so for line 7 and then line 8 you need the code.
[AGENT][NEUTRAL] Right, because it doesn't give us that description and that was all on the [PII], correct?
[AGENT][NEUTRAL] Is that right?
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Uh, no, it's, I'm sorry, my mistake. This procedure, I'm sorry, that was on [PII] because that's where we're asking for that, um, information for the CPT and, and.
[CUSTOMER][NEGATIVE] Uh, no.
[CUSTOMER][NEUTRAL] Yeah, see, this is the one that you're, this is for the biopsy, so you, so yeah, so he tried to send, OK, so he tried to send the itemized bill but he left the codes out.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right. And again, you may be able to obtain it from the surgeon. It might be a little bit easier to get those codes because the facility, so you're gonna have two sets of charges and I'm sure you are aware of this and going through treatment and you have those hospital charges and then you'll have those professional fees. And what those professional fees consist of, that's your surgeon, um, anyone that reads your, uh, your, your diagnostic. Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] Yeah, and I'm like confused. I'm like, oh my Lord Jesus file bankruptcy now.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Yeah, because like I said, a lot of times you get confused. Yeah, uh, that's good. I mean, at this point, that's what you can do. I mean, to help get whatever you can to help get through it, but yeah, that, you'll have those two sets of charges a lot of times, even for your laboratories, you're gonna have where they, the hospital through your lab. Yeah.
[CUSTOMER][POSITIVE] Oh my God. I'm keeping humor with this, um, huh.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEGATIVE] Cause I'm like, is this the same bill? That's why I keep calling you guys and I'm like, am I doing this right or, you know, I'm just like lost so I guess I'll get the hang of it, um.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] Have that where you guys' phone line out or or.
[AGENT][NEUTRAL] Yeah, like I said,
[AGENT][NEUTRAL] The, the best thing you can do, Ms. [PII], is on that first page, do you still have that first, did you, um, on your, there's a claim form that's out there for um filing, you know, for that cancer um claim form. There is an information page that's on that first page. Do you happen to have a copy of that form or no?
[CUSTOMER][POSITIVE] Wow, OK.
[AGENT][NEUTRAL] Are you aware of that?
[CUSTOMER][NEUTRAL] I do. She sent me another one in my in my email um and I could get to it, yeah, so OK, so that's fine, uh, mhm.
[AGENT][POSITIVE] OK, good.
[AGENT][NEUTRAL] OK. So the, yeah, the best thing you can do is read those instructions on that first page that when you're submitting different um when they, it kind of breaks it down for you if it's radiation or uh chemotherapy or any kind of uh any, it usually it will list it out exactly what's needed. So it kinda helps guide you to sending in the correct information.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] You don't have to go through this part of it where you're sending stuff and you, yeah, and you're thinking you're sending everything in and, and then you know, like I said, it can be very confusing especially when you have a lot of doctors and a lot of procedures going on and, you know, different diag uh different laboratories and different um diagnostic testing, you're gonna have a lot of um.
[CUSTOMER][NEUTRAL] The back and forth, OK.
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] But they should build it right though. I mean, you know what I'm saying? uh, all that should be on there. I mean really it should be on there.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Right. And unfortunately, yeah, unfortunately, because like I said, it's separate charges when it's facility, the hospital charge, and when it's the doctor's charge. Unfortunately, yeah, they're gonna be, there's gonna be information that's missed because they don't do it the same way.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] No, but I'm saying like this one here is the itemized bill, so they're getting, they are stating the bill amount of course they want that, you know what I'm saying, but they're leaving what they're the cos for what they're charging you for they're leaving that off.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] The actual procedures they're doing. Yes. Mhm. Yes.
[CUSTOMER][NEUTRAL] You know, so that's important, you know, so yeah, they're gonna have to redo that. Oh my [PII], OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, and like I said, my suggestion would be if you could reach out to the actual, uh, doctor, the surgeon that did the, you know, biopsy and see if they can provide that information. Just tell them that you have a supplemental policy and that we're requesting that information, you know, for procedure, you know, the procedure and diagnosis goes in an itemized bill and then that way they should be able to provide that for you because they know exactly what procedure was done there, the, you know, they're, they're billing that to your insurance as well, so.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, and then I could if I can't get it, I could probably call my insurance company as well too.
[AGENT][NEUTRAL] Yes, so be sure, um, like I said, you're looking at that, um, that information page with the instructions cause some services will require those explanation of benefits from your primary insurance, um, and like I said, that would consist of if you're gonna have any kind of radiation or chemotherapy or any treatment, um, you'll wanna, you'll wanna make sure you include those uh the explanation.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, I am.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] From your primary insurance because some policies are um require the actual charges some of them don't but we kind of made it so it's across the board that that's the information we ask for so that we know um we have everything as far as you know what is required when we're looking at those particular benefits.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, well, I don't know whatever they give me I'm sending it to y'all, you know, so.
[AGENT][NEUTRAL] OK. And like I said, like I said, just be sure if you're going for that, um, any kind of therapy, you know, or, you know, your radiation therapy or the chemotherapy that you include those explanation of benefits from your primary insurance as well as those itemized bills. And those usually that can be obtained from the um hospital where you're having the treatment done.
[CUSTOMER][NEUTRAL] Uh, yeah.
[AGENT][NEUTRAL] And again you would just need to let them know sometimes they have the patient portals which is helpful you can go on and download the information yourself so I'm not sure if you have a portal with them because sometimes that's helpful as well.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, I have a portal that's what was sent.
[CUSTOMER][NEUTRAL] That this bill here it was sent to my portal.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Oh it was OK.
[CUSTOMER][NEUTRAL] Yeah, yeah, so that's the reason why I uploaded it and sent it to you guys because I just got it.
[AGENT][NEUTRAL] Alright
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, but they didn't complete it, right? So I'm gonna have to reach out to them like you said.
[AGENT][NEUTRAL] Right and um yeah and unfortunately like I said I know you you don't have any control over what they put on that information and you're just, you know, we're asking for an itemized bill and that's what this says so you send it to us and then we're like no we need this we're not trying to not pay your claim we just have to be have those required, you know, documents to support um what what benefits we're paying for uh the you know under your plan.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, yeah, that's fine.
[CUSTOMER][NEUTRAL] I get it. I mean, you gotta make sure all your ducks is in a row too when you, when you submit um a claim out. I, I get it. I, I mean it makes sense. It makes sense and yeah, I don't have the code to say what they're billing for and you need the coding to pay it out, so I, I get it, yeah, OK, so I'll be, I'll work on that. I don't know, uh, I have 2 more days of school.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So, uh, school is out. I work for the school district, so, um,
[AGENT][NEUTRAL] Oh.
[AGENT][POSITIVE] It's just a few more days, so, so that's good.
[CUSTOMER][NEUTRAL] Yeah, it's short days tomorrow mhm so I probably have to work on this on Monday, yeah, will be my first day.
[CUSTOMER][NEUTRAL] Home, um, but then I have doctor's appointments, so but I'll get it done. I'll, I'll get it done. So when I do get it, do I just upload it as uh how would I.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You you just go in like you're doing a new claim you don't have to um you can just go ahead and upload the documents uh through right through that portal and what will happen is because we know that you have um information you know we'll look at that information that's already on file and see that we're asking for certain documents so as long as uh you know you you won't need to, we'll go back and look at those previous claims and because it is pending basically is what it's doing is pending for that information.
[CUSTOMER][NEUTRAL] You would just.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, good. OK, so it's not completed, it's pending.
[AGENT][NEUTRAL] Right, you know, even though it is finalized and you'll also, you should receive an explanation of benefits in the mail so just to be aware of that they'll send you that because it's gonna, um, you know, it'll have a breakdown of your payout for what was paid on these claims and then also what's being requested for that information which you've already seen it online and I'm telling you, but you will also receive an explanation of benefits from us to explain it, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Yeah, no, I didn't see it online. It just says right, it, it doesn't say it online. It just says that what does it say? It says it's not covered.
[CUSTOMER][NEGATIVE] That's what it says. It doesn't say that it's requesting anything, so that's why I called because the explanation of benefits, it just says uh not covered, not covered and then this one here I don't know what it says it says benefit name not found I don't know what that is.
[AGENT][NEUTRAL] Uh, OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Um, let me see if I can.
[AGENT][NEUTRAL] This what I'm looking at.
[CUSTOMER][NEUTRAL] The anesthesia you already went over there to benefit, OK.
[AGENT][NEUTRAL] Yeah, so that's just um the anesthesia basically it just, it's saying that the, they're based on the allowed surgery amount. So they're asking you to send the surgery charges with that itemized bill. Again, that same um information from the biopsy. So that it usually.
[AGENT][NEUTRAL] like that's on your your claim that you or I'm sorry on that itemized bill that was sent to us, I would have the um OR services on it um there should be a charge also for anesthesia and that's another thing on here it's not showing us the anesthesia but obviously we know that they use some.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well, that's a whole different bill. That's that one there is a whole different bill.
[AGENT][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That one's a whole different bill, but either way, both of them you need an itemized bill, so.
[AGENT][NEUTRAL] Right, yeah, let those procedure code.
[CUSTOMER][NEUTRAL] Yeah, so, mhm, and they didn't get it, so OK, I'll collect those two and then resend them, but what's the part where it says benefit name not found, you know what that is? It's uh PROC.
[CUSTOMER][NEUTRAL] And then it's A 95.
[CUSTOMER][NEUTRAL] 75.
[AGENT][NEUTRAL] It looks like that could have been um possibly like the contrast maybe that they use because there's a couple of different procedures and they say they're not covered because they don't cover the medicine part of it.
[AGENT][NEUTRAL] So there those J codes of the procedure, the J 7030 and then there's a J 3490 and also the A 9575. Those are usually I, I believe that a 9575 is like the contrast that they use when they do that diagnostic test so that they're just telling you that it's not covered under the plan.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, got you.
[CUSTOMER][NEUTRAL] OK, but the MRI and the biopsy you should cover the other stuff that may be involved, you may not cover.
[AGENT][NEUTRAL] And then for the screening.
[AGENT][NEUTRAL] That's right. Like I said, the incidental kind of things like the um the diagnostic, the, the dye that they use and then some of the medicine um that's used during that type of procedure that's not covered. Um, and then, of course, like I said, they did pay you that preventative screening benefit on that $50 was for the mammogram that you had on $425.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So because that was a screening that doesn't necessarily need that procedure code that's why we went ahead and paid it as a preventative service.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] So that's allowed under your plan.
[CUSTOMER][NEUTRAL] Yeah, but yeah, so that was on [PII], right, right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um, yeah, 4:25, OK, so.
[CUSTOMER][NEUTRAL] OK, but OK, so we're talking about the the MRI afterwards on [PII] and then the procedure on.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh gosh um.
[AGENT][NEUTRAL] Right, the biopsy and anesthesia charges on [PII].
[CUSTOMER][NEUTRAL] Yeah, on 4425 and 5:14. OK, there you go.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Like 5:14 info.
[CUSTOMER][NEUTRAL] And then the 425 info.
[CUSTOMER][POSITIVE] OK, I got it. OK, thank you so much for your time and help.
[AGENT][POSITIVE] Oh, you're certainly welcome, Ms. [PII]. Is there any other questions you have at this time?
[CUSTOMER][POSITIVE] I appreciate it.
[CUSTOMER][MIXED] No, you guys are gonna be so sick of me, but I'm I'm so thankful. I'm sorry.
[AGENT][POSITIVE] Well, we're here if you, if you, yeah, we're here if you need it and if you need further explanation, don't hesitate to give us a call and we'll be happy to answer any questions you might have.
[CUSTOMER][NEUTRAL] OK, so just get it and and resubmit it. OK, I got it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, ma'am. Mhm.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] You're welcome, Ms. [PII]. Have a nice evening. Thank you for calling APL. Take care.
[CUSTOMER][NEUTRAL] OK bye bye.
[CUSTOMER][NEUTRAL] You too.
[CUSTOMER][POSITIVE] OK bye bye you too.
[AGENT][NEUTRAL] Bye bye.