AccountId: 011433970860
ContactId: baf56276-09fe-47c4-8f1a-162c43eea42a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 593280 ms
Total Talk Time (AGENT): 389846 ms
Total Talk Time (CUSTOMER): 159477 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/15/baf56276-09fe-47c4-8f1a-162c43eea42a_20250115T21:08_UTC.wav
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[AGENT][NEUTRAL] For contacting APL, my name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi I'm calling in reference to an explanation of benefits.
[AGENT][POSITIVE] I can certainly help with that. And with whom am I speaking, please?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] I, I'm sorry, did you say [PII]?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] Oh, OK, [PII], thank you. What is that policy number that we're looking at today?
[CUSTOMER][NEUTRAL] It is 02286545.
[AGENT][NEUTRAL] OK, thank you. And this is your policy that we're looking at?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] If I could just verify your date of birth please ma'am, and a phone number?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Sure, [PII] and my cell is [PII]. I'm sorry, I was reaching out to put my purse away, um, sorry, [PII].
[AGENT][POSITIVE] OK, thank you very much. And what uh date of service we're looking for? What?
[CUSTOMER][NEUTRAL] [PII] and this is for my daughter [PII].
[AGENT][NEUTRAL] [PII]. OK, thank you. I'm just looking here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] So I was very surprised when I received this and it said office visits are not paid for. I uploaded the explanation of benefits.
[CUSTOMER][NEUTRAL] Um, from Blue Cross.
[CUSTOMER][NEUTRAL] Showing that the $200 and some dollar appointment.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] Went to the deductible.
[CUSTOMER][NEGATIVE] You guys have always paid it before. I don't understand what happened with this.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Of course, let's let's see what we have here so.
[AGENT][NEUTRAL] This is for um.
[AGENT][NEUTRAL] It looks like this was [PII], yes, OK, so let's look at your, at your policy.
[CUSTOMER][NEUTRAL] The provider is [PII] correct.
[AGENT][NEUTRAL] So, uh, you had a new policy that went into effect on [PII].
[AGENT][NEUTRAL] And we also look at the policy that you had before that, but let's look at the one that you have now, um.
[AGENT][NEUTRAL] Uh, the, uh, office visits are not covered on this. And so what I'm looking for now is to see the policy that you had before. Um, there was a policy that, uh, for [PII] [PII].
[AGENT][NEUTRAL] And see, I'm not I haven't seen it yet. It doesn't look like office visits are covered on, yes, uh-huh.
[CUSTOMER][NEUTRAL] Right, but this isn't
[CUSTOMER][NEUTRAL] Right, but this isn't a copay offices it was a primary.
[CUSTOMER][NEUTRAL] That's why I was confused that they processed it the way that they did. This was uh a visit with her um I think she's a psychiatrist or something.
[CUSTOMER][NEGATIVE] So there is no co-pay, it all goes to the deductible, and I could have sworn we've been compensated previously for it and I'm not trying to get a $50 co-pay back.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right. Well, this, this was, uh, this was actually listed as an office visit. Um, so let me just look at the, the claim itself because the treatment, uh, should have been covered. Uh, it's the office visit itself, um, and it, it doesn't matter, it doesn't really matter whether it's for psychiatrist or, or primary care or anything like that. It just office visits in, in particular.
[CUSTOMER][NEUTRAL] So in other words she coded it like a 99214 or something?
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Yes, let me just see what I'm just pulling up the documentation. We'll just see how that.
[AGENT][NEUTRAL] What that looks like.
[AGENT][NEUTRAL] Because yes, if it is an office visit, it doesn't really matter uh who uh what the doctor or or visit is for, uh, it would not be covered, but I'm just pulling up the paperwork that we have here that was submitted and we can just see that. Um, now, if it's for treatments, uh, that, that is completely different. So let's see. So we have in sheets, uh.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Spider
[AGENT][NEUTRAL] I'm just going through this.
[AGENT][NEUTRAL] A summary of cost.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] This, so what they did was they listed this as a
[AGENT][NEUTRAL] Is an office visit. You're saying that it is not an office visit. Is that, is that correct?
[AGENT][NEUTRAL] You're saying that this is for the service itself, or?
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] When I think about an office is that I think about paying a copay.
[CUSTOMER][NEUTRAL] For your appointment.
[CUSTOMER][NEUTRAL] And the rest goes to the insurance.
[CUSTOMER][NEUTRAL] How did she code it? Was it a 99214?
[AGENT][NEUTRAL] Well, it doesn't have a CPT code at all. Um, what it does is it just, it just has a cost. It, it says these services are, it says limitations or exclusions, these costs aren't covered in your plan. Um, so, uh, so what we have, let's see, let me just go over this.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] OK, so we have your claim status.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] This is on page 3 of the of the documentation. This is uh for [PII] uh MDPA. My total cost $200 my claim breakdown.
[AGENT][NEGATIVE] A total amount this is what uh cost for my provider for this service. It's $200. My savings is blue, uh, Florida Blue, um, and then, uh, it says, uh, it, it says what, what a coinsurance, a co-payment is, that sort of thing. And then we get down to, um, limitations or exclusions. It says these services aren't covered under your plan, and it says 0. It says my total cost and it says summary of costs.
[AGENT][NEUTRAL] Um, and that is, uh, why this was denied. um, so we're not, uh, and I do understand what you're saying about a co-payer or, or, um, a co-payment for that, um, but on the, the EOB that we received.
[AGENT][NEUTRAL] It's showing zeros and so when we looked at this that
[CUSTOMER][NEUTRAL] It didn't show it going to the deductible?
[AGENT][NEUTRAL] Um, I'm not seeing anything that shows that. I'm looking at the documentation that was that was submitted and so the very first page, uh, it's, um, shows, let's see.
[CUSTOMER][NEUTRAL] on
[AGENT][NEUTRAL] The very first page shows the [PII] PA date of visit, [PII], reason for visit and it has a diagnosis code. Um, then it says my claim status. It says my total cost, processed check at $200. My claim breakdown, cost of care from my provider.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Total amount that was the $200. My saving with Florida Blue 0. Amount my plan paid $0. My total savings for this service $0. My cost co-payment or co-pay $0. Um, my co-insurance $0. Limitations or exclusions $0. My total cost $200.
[AGENT][NEUTRAL] Um, and so when we were looking at this, uh, we, um,
[AGENT][NEUTRAL] It, it probably should have read that there was that there's no um uh first of all, what we should have asked for uh rather than just saying that it was assuming that it was an office visit, uh, because there's nothing here to indicate whether it's an office visit or treatment. And so what
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, probably a more, uh, a better way of, of, uh, denying this or pending it, I should say, is that we would need a copy of the, of the bill if there's a walkout, uh, sheet or a bill that uh Doctor Sheets provided. Um, we would need to know what the
[CUSTOMER][NEUTRAL] But I and that's what I sent to Blue Cross. OK, so let me, um, OK, so I need to look for the receipt.
[AGENT][NEUTRAL] And then I would also, when you're looking through Blue Cross and Blue Shield when you're on the portal again, um, find the one that has, and sometimes they'll do this because they just haven't processed it yet.
[AGENT][NEGATIVE] Find the one where it says my costs and it says deductible, co-payment or co-insurance. Now, on this one, it says all zeros.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEGATIVE] Yeah, it should have said deductible because it it was applied to the deductible. I saw that when I was on there I must not have caught it when I printed it out.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That's fine. That, that's usually when it's, it's confusing when you see those because you're looking at that and you're thinking, you know, this, and I've done it before where you look at that and you think, OK, I, I see it on this side, on the left hand side of the screen. I'm supposed to looking on the right, and it just, it begins looking alike to me. So I, uh, but that's you're just.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] I probably saw it on the screen and didn't realize it didn't print out that way. I'm wondering actually if I didn't send the last sheet or something with it, um, but I will definitely do that showing the deductible.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Yes, please. Yes, and if you will um just reference that claim number ending in 8524, um, and then what we will do is we will review it. um, now, bearing in mind that even so, the offices it won't be covered, but the, but the services should. And if you, uh, and we do have the uh diagnosis code which is always very important, so we would be glad to look this over and and see what we can do about getting that taken care of. Now, is this the only claim that we need to go over?
[CUSTOMER][NEUTRAL] Sure, OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I think so you guys are usually right on it.
[AGENT][NEUTRAL] OK, well then we'll be on the.
[AGENT][NEUTRAL] We'll be on the lookout for that and uh what we're doing is we're filing uh working the claims that we received on the [PII] so it shouldn't take us very long once we do receive that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, should I upload this to the website again and put something on there like OK, OK, perfect.
[AGENT][NEUTRAL] Please.
[AGENT][POSITIVE] Yeah, and just, uh, and what I would do, uh, don't put it down as a just, just say, you know, um, uh, please review that's always a good one just please review.
[CUSTOMER][NEUTRAL] Please [PII]
[AGENT][NEUTRAL] Uh, yeah, and um.
[CUSTOMER][NEUTRAL] I will send this
[AGENT][NEUTRAL] And then what we will do is look at that.
[CUSTOMER][POSITIVE] Excuse me, the denial also with it so that I know that the claim number and everything's on there. OK, perfect. You've been most helpful today. I appreciate your time.
[AGENT][NEUTRAL] Please.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you for contacting AT have a good.