AccountId: 011433970860
ContactId: c5254098-af7c-4137-8ce3-37dc412c6e78
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 587880 ms
Total Talk Time (AGENT): 275180 ms
Total Talk Time (CUSTOMER): 220602 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/30/c5254098-af7c-4137-8ce3-37dc412c6e78_20241230T20:58_UTC.wav
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[AGENT][POSITIVE] Good afternoon thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, yes ma'am. I'm calling in to see if you guys received uh some claims that we have sent over.
[AGENT][POSITIVE] Well, it would be my pleasure to assist you with that claim status. What is your name, please?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] And what is a good callback number, [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and the policy number for the patient?
[CUSTOMER][NEUTRAL] Um, the one that I am showing will be 01868865.
[AGENT][NEUTRAL] Thank you, [PII], and the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Um, that'll be for June.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] Alright, thank you, and I'll be happy to assist you with that claim status. What is the data service?
[CUSTOMER][NEUTRAL] Uh, 9-19 2024.
[AGENT][NEUTRAL] Bills now.
[CUSTOMER][NEUTRAL] 200 even.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] See if I can do my math. Oh yeah, that's easy.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] All right. And what is the facility name?
[CUSTOMER][NEUTRAL] Uh, that'll be for Health Enterprise Corp with the provider [PII].
[AGENT][NEUTRAL] Alright, thank you. [PII], we did receive that claim on [PII].
[AGENT][NEUTRAL] It was processed on tin wine.
[AGENT][NEUTRAL] And the 99214 was denied his offices are not covered.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the
[CUSTOMER][NEUTRAL] The night is what I'm sorry?
[AGENT][NEUTRAL] The 99214 was denied as office visits are not covered under the patient's plan.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The 81002.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] was denied his benefits are payable only if the major medical provides benefits.
[CUSTOMER][NEUTRAL] OK, so what plan does the patient have with you guys because I do show that they are double covered looks like you guys are secondary insurance, um, and.
[AGENT][NEUTRAL] We are secondary to their major medical.
[CUSTOMER][NEUTRAL] OK, and so what um what services do you do cover because, uh, there still is a $10 balance remaining for the patient looks like that's their copay for the visit for the office visit that their primary did cover and usually that'll fall on secondary um but you're stating that it's a non-cover charge.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's correct. Under this plan, the office visit is not covered. Now, uh, procedures and treatments performed in the doctor's office are covered under her plan, but not for the office visit co-pay.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So,
[AGENT][NEUTRAL] Now on on the 81002, according to the EOB nothing was applied to the deductible co-pay or co-insurance, therefore, no benefits were payable through APL.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] OK. Um, and so, uh, that would just go back to what um services do they do cover for this patient?
[AGENT][NEUTRAL] Gonna cover outpatient services such as diagnostic testing, but it has to be in an outpatient facility or in the doc doctor's office because she does have that office treatment rider. Um.
[AGENT][NEUTRAL] It would cover procedures or treatments performed in the doctor's office, also for outpatient surgery, emergency room, urgent care facility.
[AGENT][NEUTRAL] Um, independent laboratory, durable medical equipment.
[AGENT][NEUTRAL] But it all depends on the primary and what they apply to the deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] Got you OK and so you said that they have outpatient services but it also has to be in an outpatient setting, right?
[AGENT][NEUTRAL] Or in a doctor's office.
[CUSTOMER][NEUTRAL] Or in a doctor's office. OK. And so,
[AGENT][NEUTRAL] Yeah, just like the 81002 could be covered if the primary had applied something to the deductible or co-pay or co-insurance.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, what about the um the office visit though? Why wouldn't that one be covered if it, if you're stating that they have outpatient services.
[AGENT][NEUTRAL] For treatment.
[CUSTOMER][NEUTRAL] And this was an outpatient.
[AGENT][NEUTRAL] Well, let me just, I tell you what, let me get you to a claims department representative. They can review that claim with you. And you said it was, well, let me, let me check one thing real quick.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] See if I can get the claim pulled up and we'll because the place of service will determine that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, yeah, the place of service will be 11, which would be office.
[AGENT][NEUTRAL] Give me
[AGENT][NEGATIVE] Yeah, that's why it was denied.
[AGENT][NEUTRAL] For the visit.
[CUSTOMER][NEUTRAL] Where the visit, OK.
[AGENT][NEUTRAL] Yeah, it would have to be in an outpatient facility.
[CUSTOMER][NEUTRAL] I'm just
[AGENT][NEUTRAL] And build as an outpatient facility.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Um, I'm, I guess I'm just a little confused and I do apologize. It's just, I don't, I mean, this is an outpatient facility.
[AGENT][NEUTRAL] But the code on the bill on the HIPAA is a place of service 11.
[AGENT][NEUTRAL] And a place of service 11 is not covered under her plan for the visit, but let me get you to a representative that can review that a little further with you. Would that be OK?
[CUSTOMER][POSITIVE] That'd be perfect thank you.
[AGENT][NEUTRAL] All right. Thank you, [PII]. One moment please, ma'am.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Calling APL, my name is [PII]. How may I assist you today?
[AGENT][NEUTRAL] Hi, [PII], it's [PII]. How are you doing today?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][POSITIVE] I'm doing well, thank you. [PII]'s. Yippee.
[CUSTOMER][POSITIVE] Happy [PII].
[AGENT][NEUTRAL] Um, I have got a provider on the line.
[AGENT][NEUTRAL] That's going to need a little.
[AGENT][NEUTRAL] Um, hm.
[AGENT][NEUTRAL] How can I say it nicely? A little repetition of what I said.
[AGENT][NEUTRAL] It's on policy number 1868865.
[AGENT][NEUTRAL] And it's regarding claim number.
[AGENT][NEUTRAL] 351.
[AGENT][NEUTRAL] 22
[AGENT][NEUTRAL] 99.
[AGENT][NEGATIVE] was trying to explain that the 99214 is not covered. She's saying, but she does have the office treatment writer. We went over that and by the, you know, nothing applied in the EOB and yada yada, but she's not understanding why the 99214 is not covered if they are an outpatient facility, we went over the fact that the place of service is an 11, but she's still not understanding why it's not covered. Can you help her?
[CUSTOMER][NEUTRAL] Yeah, it is what it is and I'm gonna tell it to him. I mean that we can't rewrite the policy, but, but one thing about it, even just recently, we don't even pay it for um places of 22, so it is.
[AGENT][NEUTRAL] And her
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] And
[AGENT][NEGATIVE] And I was trying to explain to her, but she's like, uh, I don't understand why it's not covered.
[CUSTOMER][NEUTRAL] OK, I'll let her know it's in the policy.
[AGENT][NEUTRAL] Anyway, her name is, her name is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And your callback number is not, you want her callback number real quick?
[CUSTOMER][POSITIVE] I'm ready.
[CUSTOMER][NEUTRAL] Oh yeah, I'm sorry, I forgot about that.
[AGENT][POSITIVE] Not a problem. I got you. Callback number is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] And let me get her on the line. I appreciate you, [PII]. You have a great day.
[CUSTOMER][POSITIVE] Thank you. You too.
[AGENT][POSITIVE] Thank you. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] [PII], thank you for your patience. I have [PII] on the line. She's going to assist you further and have a wonderful day.
[CUSTOMER][NEUTRAL] Hi.
[CUSTOMER][POSITIVE] Awesome thank you.
[AGENT][POSITIVE] Thank you, bye bye.
[CUSTOMER][NEUTRAL] Hi, this is [PII]. I understand you had a question in regards to a claim denial.
[CUSTOMER][NEUTRAL] Yes, um, so this station is double covered. Um, they do have Blue Cross Blue Shield as primary, and then of course they have American Public Life as secondary. Uh, we did receive payment from primary. We did, uh, send over the claim to secondary. I did, um, call it in just to see because we hadn't received any EOB or anything towards this claim, so I did just wanna get an update on it, and the lady that I just spoke to did specify that, um, the CPT code 99214 was not covered, um.
[CUSTOMER][NEUTRAL] Because it was a non-covered charge, so I did just wanna get a little bit more clarification to that as, uh, to, you know, why would that be if it is an office visit and she also did tell me that outpatient office visits are covered, so I was just a little confused.
[CUSTOMER][NEUTRAL] OK, so the policy does not cover for the um.
[CUSTOMER][NEUTRAL] The charges associated with the physician's charges that co-pay that's associate associated with the physician's charges, we don't cover that. We only cover any treatment or procedures at the visit.
[CUSTOMER][NEUTRAL] OK. So then what you guys don't cover would just basically be the co-pay of the office visit.