AccountId: 011433970860
ContactId: d43d62b7-42e2-4854-ab49-855e9338077f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 618780 ms
Total Talk Time (AGENT): 174578 ms
Total Talk Time (CUSTOMER): 257269 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/24/d43d62b7-42e2-4854-ab49-855e9338077f_20250124T14:27_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] and the last name is [PII]. I'm calling for provider to check on additional information about the claim that's been denied. Please note this call will be monitored and recorded for quality and training purposes. Hi, how are you doing today?
[AGENT][NEUTRAL] So you
[AGENT][POSITIVE] I'm good. Can you spell your first name?
[CUSTOMER][POSITIVE] Absolutely. This is [PII] Can I get your name too?
[AGENT][NEUTRAL] Can you spell your first name again for me?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. [PII]
[AGENT][NEUTRAL] And then you said you need clarification of a of a deny claim?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Yes, yes, you're right.
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] Yeah, sure. It starts with the D as in Delta 43,302,090.
[AGENT][NEUTRAL] OK, what's the claim number on the ELB that you received?
[CUSTOMER][NEUTRAL] It was 354-410-0.
[AGENT][POSITIVE] And a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]. It's a direct line?
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] The correct policy number is 247.
[AGENT][NEUTRAL] 492 4.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And if you can verify the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name, I have [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you for that information. And what is the denial reason on the document that you have?
[CUSTOMER][NEGATIVE] I see this one, upon checking on my end, I see the post code [PII]. This one got denied as the allowed frequency of this service of pressure has been exceeded. Am I right with this?
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] When you
[AGENT][NEUTRAL] Still looking?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] How many is we did just to check on.
[CUSTOMER][NEUTRAL] And beyond the office.
[AGENT][NEUTRAL] And what was the total charge for that day?
[CUSTOMER][NEUTRAL] Sure. So the total bill amount I have for this one, it was on.
[CUSTOMER][NEUTRAL] One moment, please.
[CUSTOMER][NEUTRAL] Yes, so the total bill amount is $202 even.
[AGENT][NEUTRAL] OK, under that claim number that you gave me, I'm showing it denied as a duplicate. That's the remark code on the explanation of benefits. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I think you stated something different.
[CUSTOMER][NEUTRAL] Yeah, sure, sure.
[CUSTOMER][POSITIVE] Yes, you're right. Uh,
[AGENT][NEUTRAL] So I don't know what
[CUSTOMER][NEUTRAL] Actually, I just wanna confirm you that, sorry to interrupt. I just want to confirm you that uh we have submitted initially this claim on [PII]. After that, we have submitted with corrections on [PII]. That's the reason why it might be denied as a duplicate, I think so.
[AGENT][NEUTRAL] OK, so the one denied as a duplicate is the initial or is the second claim that we received the initial.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Denial reason
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I think the maximum benefit is exhausted, which I think that may have been what you said earlier, not for sure. One moment.
[CUSTOMER][NEUTRAL] Sure, sure.
[CUSTOMER][POSITIVE] Yes, yes, you're right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, the maximum benefit for the outpatient sickness rider has been exhausted for the calendar year.
[AGENT][NEUTRAL] So there were no benefits available at the time the claim was received?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, maximum benefit exhausted for the calendar year for the outpatient sickness riding, writer, am I right?
[AGENT][POSITIVE] Correct. Correct.
[CUSTOMER][NEUTRAL] One moment please, just give me a second.
[CUSTOMER][NEUTRAL] Say after sickness some word, uh, can you please spell it out for me if you don't mind?
[AGENT][NEUTRAL] Spell out what?
[CUSTOMER][NEUTRAL] That would, after outpatient sickness.
[AGENT][NEUTRAL] The office just basically the office visit benefit it's exhausted. There's 5 visits per calendar year, so the 5 was paid prior to your claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Office visits were allowed 5 per calendar year.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Right, thank you so much for that information. By the way, well, as for the code notes here, our code is stating that the patient encounter for essential hypertension for the officer patient visit for the evaluation and management of the established patient requests medically appropriate history, examination or medical decision making. When using total time on the date of encoter for code selection, 30 20 minutes must be met or exceeded to the patient. So the dinner service as per our code notes here, our code stating this one build the proper. So can you please send this back for a process? Is it possible?
[AGENT][NEGATIVE] OK, the maximum benefits sir, has been exhausted. There are no more benefits for that calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Well then, uh,
[AGENT][NEUTRAL] So the claim was processed correctly.
[CUSTOMER][NEUTRAL] OK. Well then, may I know uh when it was uh previously built?
[AGENT][NEUTRAL] You want to know when it was previously billed? I'm not sure I understand that question.
[CUSTOMER][NEUTRAL] Yes, yes, sir, uh may I know when it was previously built, uh, the last visit?
[AGENT][NEUTRAL] Yeah, it was from a different provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So we don't disclose that information it's from a different provider.
[AGENT][NEUTRAL] Just know that the maximum of 5 has already been paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So you can provide that previous history like uh under a different provider that was, I mean, like date of service and claim number, right?
[AGENT][NEUTRAL] Correct, we cannot.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Any other questions?
[CUSTOMER][NEUTRAL] Yeah, I just wanna know, do we need to bill with any different code for this service code to get payments?
[AGENT][NEUTRAL] It doesn't have anything to do with the coding. There is a max of 5 visits that we pay per calendar year. We've already received 5 office visit claims from different providers, maybe including your, your office, so we've already paid out the 5 for that year, so we're not able to pay anymore. That's the limitation under this policy 5.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So we cannot bill with any other different quote for this service because this service itself is only allowed 5 visits per calendar year, right?
[AGENT][NEUTRAL] Correct, has nothing to do with the coding. It's the number of visits that's allowed under this policy.
[CUSTOMER][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] Right, right. Well done. And can you please confirm me, is this code uh uh 99213, is it valid and billable code or not?
[AGENT][NEUTRAL] It's an office visit code, so yes.
[CUSTOMER][NEUTRAL] OK. It's a valid and, right, thank you. Any particular guidelines that we need to follow to resolve this now? Which guidances do we need to follow? Medicare or CMS?
[AGENT][NEUTRAL] OK [PII], can I speak with your supervisor please?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, all right. And uh can you please help me with the correct mailing address just for documentation purpose?
[AGENT][NEUTRAL] OK, what address do you currently have?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] I have here the address is, one moment. Yes, it's [PII], right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Right, thank you. And may I know the time refund limit to submit this correctly?
[AGENT][NEUTRAL] No timely filing limit to submit the claim.
[CUSTOMER][NEUTRAL] OK. No time. OK, right. Thank you. And uh your mailing address for this?
[AGENT][NEUTRAL] The address that you just gave me.
[CUSTOMER][NEUTRAL] Same. OK. Any attention to submit an appeal?
[AGENT][NEUTRAL] If you choose to submit an appeal, it needs to be made to attention appeals.
[CUSTOMER][NEUTRAL] Appeals, right. Family limit?
[AGENT][NEUTRAL] 180 days from the date of the adverse decision, so that would be for for the initial claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right. And any specific form needed to submit an appeal or we can go with just a formal letter?
[AGENT][NEUTRAL] Yeah, your standard form letter on the doctor's letterhead stating why you're appealing the claim.
[CUSTOMER][POSITIVE] Right, [PII]. Thank you so much for that information. Can you please help me with the call reference number for this?
[AGENT][NEUTRAL] My name and today's date, [PII]. And any other questions that I can help out with today?
[CUSTOMER][POSITIVE] No, that's all I have. Thank you so much. Thank you for your time. Hope you have a great day.
[AGENT][NEUTRAL] All right. And could I, could I speak with your supervisor, please?
[CUSTOMER][NEUTRAL] He's presently not uh here, uh, I mean.
[AGENT][POSITIVE] OK. All right, thank you for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] Right.