AccountId: 011433970860
ContactId: be9e91e5-4d43-4a94-90d7-53defdb5c4c6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1229819 ms
Total Talk Time (AGENT): 407111 ms
Total Talk Time (CUSTOMER): 419449 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/18/be9e91e5-4d43-4a94-90d7-53defdb5c4c6_20250418T12:41_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello, my name is [PII] and I'm calling from provider's office. Today I called you regarding claim denial.
[AGENT][NEUTRAL] OK, well, I'll be more than happy to help you with the claim denial and from my notes, can you spell your first name for me and provide a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, sure. My name is [PII]. So it's spelled as [PII] Last name initial is [PII], and our callback number is [PII] with the extension of [PII].
[AGENT][NEUTRAL] OK, excuse me. For the phone number you said [PII], it's too many numbers.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, only
[CUSTOMER][NEUTRAL] There are only 2 consecutive 0, not 3.
[AGENT][NEUTRAL] So [PII]?
[CUSTOMER][POSITIVE] Yes, correct. You got it.
[AGENT][NEUTRAL] OK, may I have the member's policy number?
[CUSTOMER][NEUTRAL] OK. Mm mm mm.
[CUSTOMER][NEUTRAL] It's gonna be D as in Delta 41201324.
[AGENT][NEUTRAL] And do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] On the ID card, do you see anywhere that says inpatient or outpatient policy certification number?
[CUSTOMER][NEUTRAL] OK. Let me check.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I can see the policy.
[CUSTOMER][NEUTRAL] Number 02110943.
[AGENT][NEUTRAL] OK, that's the member's policy number for APL. Hold on one moment, I'm gonna pull that policy.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm. OK. Give me one minute here.
[CUSTOMER][NEUTRAL] OK. So member's name is gonna be [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have either the date of service or the claim number for the claim you'd like to go over?
[CUSTOMER][NEUTRAL] OK. The service is gonna be [PII] and total amount $930. And claim number is 3,522,080.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm. Sure.
[AGENT][NEUTRAL] You said claim number 3,522,080?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So the
[CUSTOMER][NEUTRAL] Oh no, I do apolo. Yes, yes, correct. 352-2080, right?
[AGENT][NEUTRAL] So the claim was paid out on are you calling about the denied code on the claim?
[CUSTOMER][NEUTRAL] Yes, the CPT code 93306 is denied as a max benefit. I can see here.
[AGENT][NEUTRAL] OK, and then what questions did you have about the claim?
[CUSTOMER][NEUTRAL] So, may I know why this claim is denied as a max benefit? Because I can see the units only one with bill and I can see the previously um claims sent back for a review.
[CUSTOMER][NEUTRAL] Under the ticket number 4569782 on [PII].
[AGENT][NEUTRAL] OK, so the reason that code was denied is because of the benefit. Um, hold on one moment, I'm pulling up the policy, um, benefits so that I can give you specifics. Hold on one second, OK?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK. Take your time.
[AGENT][NEUTRAL] OK, it's coming up now. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm. Sure.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so the benefit used was the outpatient sickness rider.
[AGENT][NEUTRAL] The benefit is up to $75 per visit with a max of 5 visits per calendar year. So for the date of service,
[AGENT][NEUTRAL] [PII]. These are both on the same day, so it was applied to the first code, that was the max that could be paid. That's the most that could be paid.
[AGENT][NEUTRAL] For this policy.
[CUSTOMER][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] Within the 5 years, need to build the CPT code.
[CUSTOMER][NEUTRAL] Uh, on $75 that's what you said.
[AGENT][NEUTRAL] Right, because it's they're both on the same day, so the $75 was applied to the first code, so it can't be applied again because that's the most.
[AGENT][NEUTRAL] If it was on a different day, then it could have been applied again, but this is, it's per visit, so that's one day.
[CUSTOMER][NEUTRAL] But the CPT code was different. Code was different.
[AGENT][NEUTRAL] The code was different, but the day.
[CUSTOMER][NEUTRAL] This is the stress test code.
[CUSTOMER][NEGATIVE] And this is uh 99306 is hard.
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] It's not about the code, ma'am. It's the date of service. It's up to $75 per visit. This is the same visit, so we can only apply it once. $75 is the maximum.
[AGENT][NEUTRAL] The most.
[AGENT][NEUTRAL] So yes, it's different codes, but it's the same date of service.
[CUSTOMER][NEUTRAL] OK. Just give me one minute.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So how many visits are allowed? 50 sorry, 5 visits per calendar, right?
[AGENT][NEUTRAL] Yes, 5 visits per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And and how many visits was paid previously in [PII]? Can you tell me that?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm. OK.
[AGENT][NEUTRAL] In [PII], he used all four visits. This was one of the four.
[AGENT][NEUTRAL] And he has one more.
[CUSTOMER][NEUTRAL] For visit and
[CUSTOMER][NEUTRAL] OK. So we need, uh sorry. So on one claim, we billed twice.
[CUSTOMER][NEUTRAL] For the same services, that's why 11 got paid and one is declined. That's what you said, right?
[AGENT][NEUTRAL] I said it's the, I said it's the same date of service, so the $75 was applied to the first code.
[CUSTOMER][NEUTRAL] That's why it's not paid, but uh,
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] The benefit is up to $75 per visit, 5 visits per calendar year.
[AGENT][NEUTRAL] And this is one visit for [PII].
[CUSTOMER][NEUTRAL] Yes, I got your point. For the CPT code 93015, you paid uh this CPT, right?
[CUSTOMER][NEUTRAL] $75. That's why the CPT code was declined.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, may I know the filing limit?
[AGENT][NEUTRAL] Um, you can file at any time up to 180 days, um, after the denial date.
[CUSTOMER][NEUTRAL] May I know the denial date?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Again, the claim was denied on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Thank you. And how can we submit the medical records?
[AGENT][NEUTRAL] Medical records are not needed. The maximum was paid to the claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Or are you asking just in general, how do you submit medical records?
[AGENT][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Are you asking for the medical records in terms of this claim or just asking me in general for the address?
[CUSTOMER][NEUTRAL] General, general, normally.
[AGENT][NEUTRAL] Our mailing address is [PII].
[AGENT][NEUTRAL] Hold on one moment, let me make sure which one this goes to.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, it goes to IMA, so it's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK. Thank you so much, [PII], for helping me. And just give me one minute, OK? Stay on the line.
[AGENT][POSITIVE] OK, take your time.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yes, I, I'm still uh searching and previously we send the claim back for a review. So what is the status of that?
[AGENT][NEUTRAL] Um, when was the second claim submitted?
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] We just send, uh, we some, uh, previously, the previously they've submitted the claim as a reprocessed on [PII] and this ticket number 4569782.
[AGENT][NEUTRAL] I don't know what that number that I don't know what that number is in reference to, um.
[AGENT][NEUTRAL] There was a claim that came in in December and then [PII], but the only claim for your date of service is the claim that we went over.
[CUSTOMER][NEUTRAL] And what about previously representative
[CUSTOMER][NEUTRAL] Um, previously representative just send back for a review on this ticket ID. I need the status of that also.
[AGENT][NEUTRAL] What, what I, I don't understand what you're asking. There is no other claim on file or reprocessed claim, that is when I put the date of service in, everything that comes in for that date will populate. There's only this one line here. We only have one claim for your date of service there, we have not received a reprocessed claim or a claim to reprocess.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] We never send the uh uh claim again. We never send the corrected claim. I just, the, my question is previously representative send claim back for review.
[AGENT][NEUTRAL] What day was that? Do you have a record of the day?
[CUSTOMER][NEUTRAL] On [PII] yeah, [PII].
[AGENT][NEUTRAL] OK, there's no record here.
[CUSTOMER][NEUTRAL] And I have the ticket number.
[AGENT][NEUTRAL] Are you sure you were speaking with American Public Life? There's
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The last time we spoke with someone.
[AGENT][NEUTRAL] was [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Prior to that, it was [PII].
[AGENT][NEUTRAL] However,
[CUSTOMER][NEUTRAL] OK, let me check. Mhm.
[AGENT][NEUTRAL] We only have one claim for your date of service.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEGATIVE] So if there was something that was sent, it was not received.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Would you like to speak to a claims examiner in reference to the claim?
[CUSTOMER][NEGATIVE] I cannot understand that.
[AGENT][NEUTRAL] OK. Well, was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] What is
[CUSTOMER][NEUTRAL] Yes, and I just uh review this uh two procedure code. First one, the, this is the paid code 93015, and another code 93306. I can see here the CPT code is related with each each other, but it is not the same services.
[AGENT][NEUTRAL] And as I've explained to you prior, it's not about the procedure code. It's about the date of service. The date of service is [PII]. Yes, the codes are different, but it's not about the codes, it's the date of service.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So because it was on the same day, we can only apply the maximum benefit once and it was applied to code 93015 because it's the same claim.
[AGENT][NEUTRAL] Had this been had the 93306 been on on [PII], we could have been applied it again because that's a different visit. It's a different day, but it's the same day.
[AGENT][NEUTRAL] Which is why only one code was paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, under this claim number, uh, this 93015 got paid 3,522,080. Am I right?
[AGENT][NEUTRAL] What is the 35, 0, that's the claim number, yes, correct.
[CUSTOMER][NEUTRAL] Claim number, yes.
[CUSTOMER][NEUTRAL] So we billed only 93015, only this code on [PII].
[AGENT][NEUTRAL] No, you bill code 93015 and 93306 on this date.
[CUSTOMER][NEUTRAL] [PII], I'm just a little bit confused here. Previously, you said at the date of service, we built two different codes on the same date. That's why the 93015 is paid and another was denied. Because as per, as per the plan, you can only pay $75.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes, that's what I've been explaining to you, correct.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So if we bill 93006,
[AGENT][NEUTRAL] 93306.
[CUSTOMER][NEUTRAL] In separate claim,
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] If we submitted the corrected claim, so it was, it will be paid or not?
[AGENT][NEGATIVE] There was, we have not received the corrected claim.
[AGENT][NEUTRAL] All that makes
[CUSTOMER][NEUTRAL] No, I'm just asking you.
[AGENT][NEUTRAL] All I'm explaining to you is the reason that this, that code 93306 was not paid was because it was already paid for 93015. I then explained it.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. On the same date of service. Yes, yes. On the same date of service, only one visitor allowed, right?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Correct. Yes, that is the answer to your question. That is why 93306 was not paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, got it. You're fine.
[CUSTOMER][POSITIVE] OK. Thank you so much, [PII], for helping me today. May I have the reference number for this claim?
[AGENT][NEUTRAL] There's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Today's date. OK. Thank you. Thank you, [PII], for helping me today. And yes, that's it for today. I have only one claim.
[AGENT][POSITIVE] You're very welcome.
[AGENT][NEUTRAL] All right, um, [PII], was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] No, thank you so much, [PII], for asking me.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Have a great day. Bye-bye.
[CUSTOMER][POSITIVE] Have a great day. Bye-bye.