AccountId: 011433970860
ContactId: d0dc3ca8-939d-4529-83dd-46a661e096f2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 962349 ms
Total Talk Time (AGENT): 522576 ms
Total Talk Time (CUSTOMER): 229287 ms
Interruptions: 5
Overall Sentiment: AGENT=0, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/19/d0dc3ca8-939d-4529-83dd-46a661e096f2_20250319T20:35_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], it's [PII].
[AGENT][NEUTRAL] Hey [PII].
[CUSTOMER][NEUTRAL] Hey, I've got Miss [PII] on the phone. She's with, uh, well, [PII] is the broker, but, um, she's calling about policy number.
[CUSTOMER][NEUTRAL] 2,605,150.
[CUSTOMER][NEUTRAL] It's one of the agents insured that they filed a claim for.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And claim number 357-7290.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Was denied.
[CUSTOMER][NEUTRAL] And she's she's saying that that's not how the policy so the schedule page reads so she wants to talk to somebody so she can get some clear answers.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, I can't say I blame her, but let me get that pulled up.
[CUSTOMER][NEUTRAL] Yes, ma'am
[CUSTOMER][POSITIVE] And she's super sweet. I don't know if you talk to [PII] a lot, but she's real cool.
[AGENT][NEUTRAL] I think I've spoken to her a time or two.
[AGENT][NEUTRAL] Uh, let me see if I can actually find this policy, sir.
[AGENT][NEUTRAL] Because I didn't see one in on base.
[AGENT][NEUTRAL] Alright, let's see here.
[CUSTOMER][NEUTRAL] I'll put my notes in real quick while I got you looking at that.
[AGENT][NEUTRAL] OK, she had plan 4.
[AGENT][NEUTRAL] Of course there's not. Why would there be? That would be too easy.
[AGENT][NEUTRAL] OK, let me get the claim pulled up and let me see what's going on.
[AGENT][NEUTRAL] I'm wondering if it's a place of service issue.
[AGENT][POSITIVE] But I don't know because I got, I gotta look at that because she's got a lot of benefits so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Well she mentioned all the places of service and she said it should fall under one of those.
[AGENT][NEUTRAL] Let's see X-ray.
[AGENT][NEUTRAL] Not right now
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Chiropractic care. hmm.
[CUSTOMER][NEUTRAL] You should I get back to her and let her know that you're searching?
[AGENT][NEUTRAL] Yeah let her know that I'm pulling up what was submitted so I can try and figure out what's going on here.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] OK, alright, I'm gonna go back to her real quick.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] Oh OK, she's good.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So.
[AGENT][NEGATIVE] There's not a place of service code.
[AGENT][NEUTRAL] There's just a patient statement here.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Does she happen to know how like what place of service code they use?
[CUSTOMER][NEUTRAL] I am not sure she will probably she would probably know because [PII] is the one that filed the claim for her so she may have information.
[AGENT][NEUTRAL] OK, I can ask her about that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, because the only thing I'm thinking is they have outpatient accident and sickness in a physician's office.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And so.
[AGENT][NEUTRAL] It appears to be maybe a physician's office because it is.
[AGENT][NEUTRAL] Yeah. Uh, I don't know if that's Homa, Huma. I don't, I think it's Homahibido spine and rehab. I would assume that's a physician's office, but I really don't know. Um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] But we don't have a place of service code. I don't even know if there's an EOB note on here that kind of clarifies like hey we need.
[AGENT][NEUTRAL] Clarification? There's not.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, yeah, let me talk to her and see if she has more information so that I can kind of nail down what may we may be able to do or not do here.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. OK, [PII], I appreciate you helping her. You're welcome. All right, bye-bye.
[AGENT][POSITIVE] Thank you, no problem.
[AGENT][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Ms. [PII]?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Hey this is [PII] in the claims department. How are you?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] I'm doing well um OK so I'm looking at what we have what you submitted for us, and my only question is.
[AGENT][NEUTRAL] I can make assumptions here, but I want to.
[AGENT][NEUTRAL] Clarify, do you know what place of service code would have been used? Do you have that information by chance?
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] The place, like the, the place she was treated at service code?
[AGENT][NEUTRAL] Yeah, so, yeah, so there's like, you know, if it's a telehealth, the place of service code is 02. If we receive lab charges from like Quest Diagnostic, the place of service code is 81. So do you happen to know what their place of service code is for this particular facility?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Not sure.
[AGENT][NEUTRAL] OK, um, the only reason I ask is because you know we can make assumptions but we don't have that information. I do agree that there is a very real possibility for coverage here, um, but I don't, I don't know what the place of service code is to be able to definitively say.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] We should have considered benefits here, you know what I'm saying?
[CUSTOMER][NEUTRAL] OK, so what kind of document can she get from them that shows.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] What their service code is because it does show like major medical.
[AGENT][NEUTRAL] It does show major medical, but that is likely.
[CUSTOMER][NEUTRAL] On
[CUSTOMER][NEUTRAL] Forgot where I saw that.
[AGENT][NEUTRAL] Um, I see it on the bill, but that is likely the statement after major medical has paid, um, because it shows balance forward and then it shows all this information and then.
[AGENT][NEUTRAL] You know it's showing charge what the insurance paid what the what the patient is gonna owe and then it kind of adds up her stuff so my assumption is this is after major medical has paid, which you know we are not um so there's not a place of service code we did have diagnosis codes in the records so that, you know, is fine. The only I wonder I'm gonna look up here and see if they have a tax ID.
[AGENT][NEUTRAL] Sometimes the tax ID.
[CUSTOMER][NEUTRAL] Yeah, that's what I was trying to look up the, the doctor's name to see if maybe there's any additional information under him for the facility.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] See if I have like an NPI or a tax ID or something that I might be able to obtain.
[AGENT][NEUTRAL] Something with um.
[AGENT][NEUTRAL] I see a signature.
[AGENT][NEUTRAL] With him being chiropractic, I feel like it's probably.
[AGENT][NEGATIVE] I don't want to assume because I feel like that's given false hope.
[AGENT][NEUTRAL] But I mean, I've seen a chiropractor 9 times out of 10, they use place of service 11, um, which is a physician's office because they are, they do have a doctorate. Um, they are physicians, it has a different number.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I'm trying to see if I have their tax ID.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Um, and that, to my knowledge, there is not a specific code for chiropractors because they are considered physicians.
[CUSTOMER][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Um, yeah, I don't see one on this list.
[AGENT][NEGATIVE] But I don't have one. That is my only assumption as to why this would have been denied.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Sorry, my dogs are going crazy.
[AGENT][NEUTRAL] It's OK
[CUSTOMER][NEUTRAL] Um, OK, I think I have the tax ID number. Let me just.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][POSITIVE] Maybe that'll help.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm just trying to read the handwriting we have on file.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um, maybe if I make it bigger.
[CUSTOMER][NEUTRAL] Uh, I have a TIN number.
[AGENT][NEUTRAL] OK, what's that?
[CUSTOMER][NEUTRAL] Tax identification number that's it, right? Um, it's [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm gonna look up his name to Borland.
[CUSTOMER][NEUTRAL] I just wanna make sure when I tell her like, you know, the reason it was denied like it's actually correct and I'm not just.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Cause I know she's not gonna take, you know, people usually don't take that very well.
[AGENT][NEUTRAL] Yeah, yeah, no, of course, of course. OK, so I found the spine and rehab clinic.
[AGENT][NEUTRAL] Um,
[AGENT][POSITIVE] You know what? let me do this for you. Can I get a good contact number? I'm gonna reach out to them directly and ask them.
[AGENT][NEUTRAL] What place of service code they use.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, um, and then also for the accident policy I know that that 350 was paid out but.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 50 was for treatment and then 300 was for an X-ray. But under the benefit, I thought it was 150 for an office visit.
[AGENT][NEUTRAL] Uh, let me get her accident policy pulled up as well.
[AGENT][NEUTRAL] Let's see, so for.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, she was.
[CUSTOMER][NEUTRAL] I think they paid maybe a physical therapy benefit instead of the initial doctor's visit benefit.
[AGENT][NEUTRAL] Got you, OK.
[AGENT][NEUTRAL] Um, I see extended chiropractic care on here.
[AGENT][NEUTRAL] Let's see, let me, let me just pull up what it is that they paid. That'll be helpful.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, they, they paid extended treatment.
[AGENT][NEUTRAL] OK, so they pay the extended treatment for chiropractic care and that is $50.
[AGENT][NEUTRAL] And then,
[AGENT][NEUTRAL] They paid for the X-ray.
[AGENT][NEUTRAL] $300.
[AGENT][NEUTRAL] So extended treatment.
[AGENT][NEGATIVE] On my end it does only show 50 they did not pay like an initial physician's fee or anything like that um.
[AGENT][NEUTRAL] Let's see, I'm trying to see what that benefit looks like.
[AGENT][NEUTRAL] Component that's not yet restoration.
[AGENT][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] So they have an initial rehabilitation fee, which I don't think it that's 150, then there's a physician's office treatment of 100.
[AGENT][NEUTRAL] OK, I see the physicians.
[AGENT][NEUTRAL] Yeah, I do see the physician's office treatment benefit of 100. So yeah, so because that is a chiropractic code that 98941, they paid the chiropractor, the extended treatment chiropractor code.
[AGENT][NEUTRAL] Um, our benefit at 50 and then they pay the X-ray at 300, um.
[CUSTOMER][NEUTRAL] OK, when you look into the service code, um, can you also look into seeing if she should have gotten paid either the initial rehabilitation or the physician's office treatment because this was her initial visit. It wasn't like extended treatment.
[AGENT][NEUTRAL] OK, so she.
[CUSTOMER][NEUTRAL] As far as I know.
[CUSTOMER][NEUTRAL] So I just wanna make sure she's being paid which is she.
[AGENT][NEUTRAL] She did not go anywhere else. She just went straight to him.
[CUSTOMER][NEUTRAL] Yes, as far as I know.
[AGENT][NEUTRAL] OK, OK, um, yes, I will look into this policy and kind of see how the verbiage reads on that so that I can kind of get a better idea of what the mindset may have been and how we pay um on that policy because sometimes the verbiage is tricky truthfully, um.
[CUSTOMER][NEUTRAL] OK, yeah, no, I understand.
[AGENT][NEUTRAL] OK, so let me, let me get your call back and then I will look into her accident in regards to that either the physician's office or the rehab, um, and I will look into what their place of service code is.
[CUSTOMER][NEUTRAL] OK, yeah, no, uh, let me know when you're ready for my number.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, alright, let me see if I can get in touch with them and hopefully I can get a response. I will let you know for sure if I can't as far as her hospital indemnity plan, I would say that if we can't determine just by a call to them, um, the best thing to provide that information is gonna be a CMS 1500 which is what they the type of bill that they would send.
[AGENT][NEUTRAL] Um, major medical.
[AGENT][NEUTRAL] Um, it includes their place of service, so I'll try to reach them if we can't get in touch with them I would say getting that and resubmitting, resubmitting it for review and reconsideration, um, may be our best route since we, we can't determine that based off of what we have right now.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, I appreciate your help and what was your name again?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][POSITIVE] Thank you [PII] you were very helpful. I appreciate it bye.
[AGENT][POSITIVE] You're very welcome. You're very welcome. I'll, I'll talk to you soon.
[CUSTOMER][NEUTRAL] OK bye.
[AGENT][NEUTRAL] Alright bye bye.