AccountId: 011433970860
ContactId: bcff6e1d-6768-4383-baab-634ae30c7428
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 772760 ms
Total Talk Time (AGENT): 193671 ms
Total Talk Time (CUSTOMER): 348656 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/bcff6e1d-6768-4383-baab-634ae30c7428_20250121T19:27_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII]. I'm calling for provider to check on additional information about a claim that has denied. Please note this call is being monitored and recorded for quality and training purposes. Actually, I have checked the UOB which is being denied stating that these are
[CUSTOMER][NEUTRAL] policy providers, no benefits for treatment or condition other than sickness or injury as defined by the policy. Can you please help me with additional clarification on the denial?
[AGENT][NEUTRAL] OK, Ms. [PII], can you give me your callback number, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and I can help you with the claim. Can you give me the insured's name?
[CUSTOMER][NEUTRAL] Sure. It is [PII].
[AGENT][NEUTRAL] OK, and the insured's date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the insured's policy number, please?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The policy number is 02138252.
[AGENT][NEUTRAL] OK, let me pull that up real quick.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. And then, um, what is the claim number?
[CUSTOMER][NEUTRAL] OK, sure. One moment.
[CUSTOMER][NEUTRAL] Almost there, ma'am.
[CUSTOMER][NEUTRAL] [PII] and
[CUSTOMER][NEUTRAL] The claim number is 3542016.
[AGENT][NEUTRAL] OK, let me pull in that claim real quick.
[AGENT][NEUTRAL] OK, and what is the name of the facility you're calling for?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Name of the facility is Ascension Waco.
[AGENT][NEUTRAL] OK, I'm not showing.
[AGENT][NEUTRAL] That that claim number matches the facility that you're calling from.
[CUSTOMER][NEUTRAL] OK. One moment. I'll provide you the uh exact name.
[AGENT][POSITIVE] Yes, ma'am. Thank you.
[CUSTOMER][NEUTRAL] It is the Providence Health Alliance.
[AGENT][POSITIVE] Yes, that's correct. Thank you, ma'am.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me look it up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the claim was denied.
[AGENT][NEUTRAL] Because for the patient's policy,
[AGENT][NEUTRAL] The policy does not provide benefits for the treatment of conditions unless they are sickness or injury.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So only sickness and injury is covered.
[AGENT][NEUTRAL] If it's for anything other than a sickness or injury, then the policy does not provide benefits.
[CUSTOMER][NEUTRAL] Actually, here, patient is encounter for administration of influenza vaccine. For this provider performed influenza virus vaccine trivalent derived from cell culture subunit antibiotic-free 0.5 mL doses for intramuscular use to patient on data service [PII].
[CUSTOMER][NEUTRAL] But we were receiving denial and you stated that uh code is stating that it is uh coded for the building of service. OK. Um, is it non-covered under the member's plan?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Can we send a corrected claim with the alternate CPT and can you provide me the alternate CPT to be used on this claim?
[AGENT][NEUTRAL] No, ma'am, I can't do that.
[CUSTOMER][NEUTRAL] OK, but we can send corrected claim with alternate CPT.
[AGENT][NEUTRAL] Right, if you want to send it in the correct claim correction we'll just need a letter Y.
[AGENT][NEUTRAL] You're sending in the claim correction along with it.
[CUSTOMER][NEUTRAL] OK. No alternate City provided. OK. And you're following the Medicare guidelines or American Public Life Insurance guidelines?
[AGENT][NEUTRAL] Our own guidelines, APL.
[CUSTOMER][NEUTRAL] Following.
[CUSTOMER][NEUTRAL] American Public Life.
[CUSTOMER][NEUTRAL] Right?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] American public life guidelines. Do you have information whether the procedure codes are payable codes or not?
[AGENT][NEUTRAL] No, ma'am, you're just gonna, if you need to correct the claim, you just need to send it in with the reason why you're correcting it.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm, OK.
[CUSTOMER][NEUTRAL] They will go on. Can you please verify with the corrected claims mailing address? On my end, I'm having corrected claims mailing address as [PII], OK. [PII].
[AGENT][NEUTRAL] Yes, it's [PII], [PII], but the zip code is [PII], and yes, [PII] is the end.
[CUSTOMER][NEUTRAL] Zip code is [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yes, that's the one I have stated [PII] and timely filing limit is?
[AGENT][NEUTRAL] There isn't one.
[CUSTOMER][NEUTRAL] No timely filing limit for character claims. OK. Will the reconsideration mailing address and timely filing limit will be same as the character claims mailing address and timely filing limit?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, it'll be the address that we just
[AGENT][NEUTRAL] Verified
[AGENT][NEGATIVE] And there is not a timely filing limit.
[CUSTOMER][NEUTRAL] Is there any attention to while sending reconsideration?
[AGENT][NEUTRAL] Yes, just send it to attention claims.
[CUSTOMER][NEUTRAL] Any specific form required while sending reconsideration?
[AGENT][NEUTRAL] Yes, you need to send a letter stating why you need a correction.
[CUSTOMER][NEUTRAL] But there is no specific form.
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] OK. Thank you. And can I get the call reference number for this claim so that we can move to the next claim?
[AGENT][NEUTRAL] Yes, it is my name and today's date.
[AGENT][NEUTRAL] And I'm gonna have to get off the phone and have you call back for the next claim.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Only one claim, ma'am.
[CUSTOMER][NEUTRAL] Otherwise, can you transfer me?
[AGENT][NEUTRAL] OK. What's the second claim?
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Actually forward your name.
[AGENT][NEUTRAL] My name is [PII]
[CUSTOMER][NEUTRAL] OK, and the call reference number is TORY only?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Yes, and today's date.
[CUSTOMER][NEUTRAL] OK, and today's date.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And you need the claim number for the next one?
[AGENT][NEUTRAL] Is the next one also a claim that you have questions about like the first one?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, what is the patient's name?
[CUSTOMER][NEUTRAL] Patient's name is [PII].
[AGENT][NEUTRAL] OK, and patient's date of birth?
[CUSTOMER][NEUTRAL] Patient's date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. And then what is the patient's policy number?
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] Patient's policy number is
[CUSTOMER][NEUTRAL] 02138252
[AGENT][NEUTRAL] OK, let me pull that policy up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, thank you and then what is the date of service for Adin?
[CUSTOMER][NEUTRAL] Data service is [PII].
[AGENT][NEUTRAL] OK, and then what is the claim number?
[CUSTOMER][NEUTRAL] Claim number is 3542015.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And then what is the name of the facility?
[CUSTOMER][NEUTRAL] Name of the facility is the same as the previous one which is uh
[CUSTOMER][NEUTRAL] Providence Health.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, let me pull in that claim number real quick.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Here also the same procedure codes 9046090661 are being denied. Uh, as the policy providers no benefits for treatment of condition other than the sickness or injury as defined by the policy. Here, patient has encountered uh for flu immunization for this provider performed.
[CUSTOMER][NEUTRAL] Influenza virus vaccine prevalent derived from cell culture subunit antibiotic-free 0.5 mL doses for intramuscular use immunization administration through 18 years of age via any route of administration with counseling by physician or other qualified healthcare professional, first or only component of each vaccine or toxic administered to the patient.
[CUSTOMER][NEUTRAL] On date of service [PII]. Can you please help me with additional clarification on this?
[AGENT][NEUTRAL] Uh, it's the same situation that the first one was, unless it's accident or sickness, which does not mean immunization is not an accident or a sickness. It's not covered.
[CUSTOMER][NEUTRAL] OK, non-covered as per member's plan and we can send the claim with CPT but no alternate CPT you have and following American public life guidelines and you don't have information payable code or not. Same character claims mailing address and no timely filing, same reconsiderations mailing.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Address and not filing limit like previous.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK, thank you. The call reference going to the same or?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] Name and date. OK. Thank you, [PII]. Thank you for your assistance and have a good rest of your day. Bye for now.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] You too, Ms. [PII]. Thank you. You have a good week. Thanks for calling APL.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][POSITIVE] Thank you bye bye.