AccountId: 011433970860
ContactId: be84ae05-4c89-4c36-bd12-559a53157529
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 473329 ms
Total Talk Time (AGENT): 195407 ms
Total Talk Time (CUSTOMER): 159159 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/08/be84ae05-4c89-4c36-bd12-559a53157529_20250108T19:32_UTC.wav
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[AGENT][NEUTRAL] For calling APL, this is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is from Broker Resources. Um, I've got a broker's office online and um they are calling.
[AGENT][NEUTRAL] I could barely hear you.
[CUSTOMER][NEUTRAL] This is [PII] from Broker Resources.
[CUSTOMER][NEUTRAL] And I've got, I've got a broker's office online and they're calling about one of their insureds um to find out why a claim was denied or not paid.
[AGENT][NEUTRAL] Hey, [PII].
[CUSTOMER][NEUTRAL] And they're looking for some additional information.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] What's the policy number?
[CUSTOMER][NEUTRAL] It is 233.
[CUSTOMER][NEUTRAL] 7224 for [PII].
[AGENT][NEUTRAL] And who's the broker?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Um, it's the broker's office. Um, uh, his name is [PII], so, um, are you able to speak with him?
[AGENT][NEUTRAL] What is the, the mem the um person's name on the phone? It's like your phone. I'm not sure if you're on a speaker phone or away from the phone. I'm not sure.
[CUSTOMER][NEUTRAL] I'm not, I've got my headset on, um, his name is [PII].
[CUSTOMER][NEUTRAL] It is
[AGENT][NEUTRAL] OK, let me see if [PII] is on the thing on his, on the there's a form. You can send him over. I'll be able to let him know if I can't talk to him or not.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][POSITIVE] OK perfect thank you.
[AGENT][POSITIVE] You're welcome. Have a good one.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hey, [PII], how are you doing?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] I'm great, thanks for asking. [PII]. My name is [PII]. You're calling to check the status of a claim. Could you verify that patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh, yeah, her name is uh [PII]. Uh, her date of birth, I don't know offhand, but I can look it up.
[AGENT][NEUTRAL] Yeah, cause I'm gonna need that due to HIPAA violations protocols.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK, give me one second, gotta pull up an old census.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Alright, her date of birth is [PII].
[AGENT][NEUTRAL] And what city and state does she live in?
[CUSTOMER][NEUTRAL] Uh, I believe it's [PII].
[AGENT][NEUTRAL] And you're calling to check the status of a claim for what date of service?
[CUSTOMER][NEUTRAL] Uh, so the last, what she sent me was.
[CUSTOMER][NEUTRAL] Let's see, it says the check dates on it is [PII].
[CUSTOMER][NEUTRAL] And give you a claim number as well.
[AGENT][NEUTRAL] What's the claim number?
[CUSTOMER][NEUTRAL] It is 353-359-8.
[AGENT][NEUTRAL] The data service [PII].
[CUSTOMER][NEUTRAL] Uh, yes.
[AGENT][NEUTRAL] So there was no payment on procedure code 99203 because office visits are not covered under the policy.
[AGENT][NEUTRAL] Which is considered as a duplicate, so that means that she submitted it once and we denied it this office visits not covered, but she's been, she submitted it a second time, so it's considered as a duplicate. Then for procedure code, go ahead.
[CUSTOMER][NEUTRAL] Well, it, it.
[CUSTOMER][NEUTRAL] So, so it's just that the service description says it's an outpatient expense, so I'm not.
[AGENT][NEUTRAL] Right here for, so.
[CUSTOMER][NEUTRAL] Uh, and then when I
[AGENT][NEUTRAL] OK, so there's multiple procedure codes on this claim, so I gave you one procedure code of the 3 that's listed on the claim, and I was about to give you a second one but you.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh OK my apologies.
[AGENT][NEUTRAL] So for procedure code of 71046, there was no payment made on this claim because we're requesting for the diagnosis codes which she has not provided us.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Would that also be an 8 so when I look at the forms that I submitted.
[CUSTOMER][NEUTRAL] For, uh, it says ADJ code would that be it?
[AGENT][NEUTRAL] No, that'll be the CPT code. We need the ICD 10 code, which would be an alphabet, two letters, the dot in another letter or may just be alphabet in two letters depending on what's the procedure to the diagnosis code.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK and.
[CUSTOMER][NEUTRAL] So what she sent me from [PII].
[CUSTOMER][NEUTRAL] I guess is all that
[CUSTOMER][NEUTRAL] All that she received from [PII].
[AGENT][NEGATIVE] It's not.
[AGENT][NEUTRAL] So she has to reach out to the facility where she received the services from to get the diagnosis code. I don't think she's gonna get that from her primary insurance company.
[CUSTOMER][NEUTRAL] Uh, OK, and if we get that, then the claim will be honored?
[AGENT][NEUTRAL] So if she gets that and her benefits have not been exhausted, then that pro that procedure of 71046 will be paid whatever is owed on there when she's sending the requested information that we needed.
[CUSTOMER][NEUTRAL] OK, and you said that diagnostic code, it's it what's the format that that comes in again?
[AGENT][NEUTRAL] Like it'll be.
[AGENT][NEUTRAL] Like a M well, just speaking in particular, a letter in two digits or sometimes four digits, but it's gonna be like um say for an example, M51.16 or M51, it's just gonna be a diagnosis code.
[AGENT][NEUTRAL] Start with the letter and then, but it's not a procedure code. The CPT code and the diagnosis code is two different things. Then she also had one for a facility charge, which we requested something we requested something for that one as well, information for that one as well and what she submitted was a duplicate of the original claim that she submitted.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, so, um.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So we we need to reach out to the um.
[CUSTOMER][NEUTRAL] Where where she had the procedure to get that diagnostic code thing.
[AGENT][NEUTRAL] Mhm we need it for the facility charge.
[AGENT][NEUTRAL] And the procedure code is 71046.
[CUSTOMER][NEUTRAL] And the procedure code you said?
[AGENT][NEUTRAL] No, we need to diagnosis codes for procedure code of 71046 and the facility charge for the same data service of 426 of 2024.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right
[AGENT][NEUTRAL] Alright, is there anything else that I can assist you with?
[CUSTOMER][NEUTRAL] All right, I'll uh see if we can get that.
[CUSTOMER][NEUTRAL] Uh, no, that is it.
[AGENT][POSITIVE] Alright [PII] well thanks for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] Alright you as well thanks bye.
[AGENT][POSITIVE] Thanks. Goodbye.