AccountId: 011433970860
ContactId: ba424fee-8b0c-4ae8-b368-1be01d481531
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 828119 ms
Total Talk Time (AGENT): 290822 ms
Total Talk Time (CUSTOMER): 319370 ms
Interruptions: 2
Overall Sentiment: AGENT=-0.1, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/20/ba424fee-8b0c-4ae8-b368-1be01d481531_20250520T21:10_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Yes, hi, good afternoon. Um, I'm calling because, um, I went, I was gonna go to therapy and I called you guys to see if it was covered, and you guys told me I was covered to $2500 that I did not have to have any co-payment and it was covered. I gave the information to the place that they did the therapy, and you guys told them as well that I didn't have to pay anything, that it was covered. Now I see that I'm getting um.
[CUSTOMER][NEGATIVE] Documentation from you guys and a bill from them that you guys did not cover it.
[AGENT][NEUTRAL] OK, uh, what is your name and policy number? I can look at to see if we can receive a claim?
[CUSTOMER][NEUTRAL] My name?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] Oh, [PII] and the group number is that what you need?
[AGENT][NEUTRAL] No, ma'am. Policy number or may I say policy certificate number?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK. It's 025.
[CUSTOMER][NEUTRAL] 01816 M as in Mary, L as in Larry number 7.
[AGENT][NEUTRAL] OK, thank you. And Mr. [PII] let's verify, uh, do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Uh yes, [PII].
[AGENT][NEUTRAL] OK, and verify your date of birth, mailing address and the email address, please.
[CUSTOMER][NEUTRAL] [PII] and the email is [PII].
[AGENT][NEUTRAL] OK, and mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. And do you happen to have the data of service or when you had the, you said physical therapy?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'll tell you
[CUSTOMER][NEUTRAL] Yeah, you guys send it to me. They have here.
[CUSTOMER][NEUTRAL] Um, 421.
[CUSTOMER][NEUTRAL] I don't, and 423.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] 7
[AGENT][NEUTRAL] OK, I show that claim for those two dates processed as.
[AGENT][NEUTRAL] Occupational therapy, physiology therapy or speech therapy is not covered under the policy.
[CUSTOMER][NEGATIVE] OK, when I called, and when they called, you guys told me it was. If not, I wouldn't have gone to those therapies. And every time I would go, they told me that I was covered. Now it seems like you guys don't want to pay for it, and now I'm getting billed for all these therapies. Why was I misinformed?
[AGENT][NEUTRAL] Well, these are not physical therapy charges. These are other charges that is not relation to physical therapy cause physical therapy is covered under the policy.
[CUSTOMER][NEGATIVE] And they were misinformed.
[CUSTOMER][NEGATIVE] And what is it that they, they're um doing, cause I don't understand. See what they did was um physical therapy.
[AGENT][NEUTRAL] Um, not per the information we received. Give me one moment please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEGATIVE] Cause when they called, I'm sure they said what I was going to be treated for. You get me?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] See, I might have to transfer you to an examiner because they can pull up the information on the claim that shows it was not for physical therapy, but give me one moment please.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Transferring.
[AGENT][NEUTRAL] processing.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][POSITIVE] Hey [PII], it's Kiki and care team. How are you today?
[CUSTOMER][POSITIVE] I'm good how are you [PII]?
[AGENT][NEUTRAL] Uh, I feel like I need a nap, but I took, but I took a nap at lunch. You think I would be, but it went so fast I didn't even feel like I went to sleep.
[CUSTOMER][NEUTRAL] Same.
[CUSTOMER][NEUTRAL] Oh God
[CUSTOMER][NEGATIVE] I was [PII] and say that hour just is not long enough. By the time you fall asleep, you're having to turn around and wake up and then you're just mad.
[AGENT][NEUTRAL] Right, cause usually like nap time for me is like 2 hours at least.
[CUSTOMER][POSITIVE] Oh easy, yeah.
[AGENT][NEGATIVE] But this, it was just like, what in the world did I even go to sleep? Um,
[CUSTOMER][NEUTRAL] I know it.
[CUSTOMER][NEUTRAL] I know it.
[AGENT][NEUTRAL] Can you help with the Metlink claim?
[CUSTOMER][NEUTRAL] I should be able to, yeah.
[AGENT][NEGATIVE] OK. I have an insured on the phone. She's a little irritated. Um.
[AGENT][NEUTRAL] And I was trying, I forgot how to pull up the information to show cause she thought that physical therapy was covered, which it is, but apparently the claim was processed as uh OT, KT and ST not covered.
[AGENT][NEUTRAL] But I'm trying to find on the claim where it shows what type of service was performed and I thought by that is it by the um.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] NPI number.
[AGENT][NEUTRAL] Well, I don't know.
[CUSTOMER][NEUTRAL] Um, usually they can, but sometimes the codes that they use like that they bill are an indicator of the type of services, so, um, what's your policy number?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 250-1816. I do well.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] I put in the code, the
[AGENT][NEUTRAL] But didn't say.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I used to process these long time ago, but I forgot.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] It's OK, um, what's the claim nu[PII] that we're looking at?
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] 3600737.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, let's see what we got going on here.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] So this is saying kinesiology, speech or occupational therapy are not covered.
[CUSTOMER][NEUTRAL] I think it's gonna be that modifier.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] I know how to look up a modifier.
[CUSTOMER][NEUTRAL] Let me double
[CUSTOMER][NEUTRAL] It's gonna be something that I don't think it's just out there in our system to look at it would be helpful for examiners at least but for you guys too I'm sure.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, so.
[CUSTOMER][NEUTRAL] Let's see, well, no, that just says that the modifier G 0 is telehealth services.
[CUSTOMER][NEUTRAL] For acute stroke, um, let me.
[AGENT][NEUTRAL] How do
[AGENT][NEGATIVE] How are you gonna do therapy at the telehealth? I just don't get these people.
[CUSTOMER][NEGATIVE] I don't think that's right.
[CUSTOMER][NEUTRAL] Yeah, I don't think um that I wonder if that's GO and not G0. That's what I'm thinking it might be. Let me see.
[AGENT][NEUTRAL] I was Geo.
[AGENT][NEUTRAL] I remember a long time ago someone asked, Can we do dental telehealth? I was like, how does that work? How are you gonna not.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] I mean, you need to be present in order for.
[CUSTOMER][NEUTRAL] I mean, unless it's like a.
[CUSTOMER][NEUTRAL] Toothache or something or you just so.
[AGENT][NEUTRAL] It's like, can you look at this too for me, please?
[CUSTOMER][NEUTRAL] GO right GO with services delivered under an outpatient occupational therapy plan of care.
[AGENT][NEUTRAL] Oh, so it was.
[CUSTOMER][NEUTRAL] I think that's what it's supposed to be mhm so I think it's GO not G 0.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And so for the therapeutic exercises and stuff like that, like that's fine, but when you look up that code, it's occupational therapy and they.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] don't have occupational that I'm aware of. They only have physical therapy.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] We have physical, yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So, part of the codes, I'll tell her that she's gonna have to talk to her doctor.
[CUSTOMER][NEUTRAL] Yeah, just tell her right per the way that it was billed, it was not for physical therapy, which is covered, it's for occupational therapy and part of the remark code, it does not state that her physical therapy is not covered. It states that kinesiology, speech, and occupational therapy are not covered.
[AGENT][NEUTRAL] Awesome. I was informed her and how much is this claim? I'm being nosy. I'm sorry.
[CUSTOMER][NEUTRAL] Your phone.
[CUSTOMER][NEUTRAL] Let's see.
[AGENT][NEGATIVE] 0 $92. At first I thought it was like $1 so I was like, what? You might have a dollar, you better go and give him $2 bill.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Right, come on, yeah.
[AGENT][NEUTRAL] Well y'all was supposed to pay, but whatever. All right, thank you.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] Right. You're welcome.
[AGENT][POSITIVE] All right. Have a good one.
[CUSTOMER][NEUTRAL] [PII], you too.
[AGENT][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Come to dial an extension or for any other inquiries.
[AGENT][NEUTRAL] Uh, Mr. [PII].
[AGENT][NEUTRAL] OK, thank you so much for holding. I spoke with the examiner and looks at the claim and per the procedure codes on here, it indicates for occupational therapy, which is not covered under the policy. The policy does cover physical therapy, but the codes indicate occupational therapy.
[CUSTOMER][NEUTRAL] And what's, what's occupational therapy?
[AGENT][NEUTRAL] Um, I don't know. I have to Google, but it's not considered physical therapy. Give me one moment.
[CUSTOMER][NEUTRAL] Well, yeah, because what they gave me was um physical therapy, it was an occupational.
[AGENT][NEUTRAL] Uh, that's part of the codes on the claim that they submitted to us. Uh, occupational therapy aims to help individuals engage in meaningful daily activities, occupations such as self-care, work, or leisure. OT works to improve, fun, and growth motor skills, cognitive abilities, and adapt adapting environments to enhance independence.
[CUSTOMER][NEUTRAL] I know, what is that?
[AGENT][NEUTRAL] Physical therapy concentrating on restoring movement and function through exercise, manual therapy, or rehabilitative techniques. PT helps patients recover from injury, surgery, or chronic pain. But um like I said, per the information we received, it shows occupational therapy.
[CUSTOMER][POSITIVE] Wow.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] OK, let me call them and leave a message because they're already closed, so they can explain to me because what from what I know was physical therapy, it wasn't occupational. And when they called, they gave you guys, I guess the wrong information, that's why you guys said it was covered, but then they, they did something else, it doesn't make sense.
[CUSTOMER][NEUTRAL] OK, let me call them then let me leave a message for them.
[AGENT][POSITIVE] OK, uh thank you for calling APL and you have a great day.
[CUSTOMER][POSITIVE] Thank you. You too. Bye-bye.
[AGENT][NEUTRAL] Bye.