AccountId: 011433970860
ContactId: d93cc4b3-5f85-4de3-9c62-aea166d99963
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 911109 ms
Total Talk Time (AGENT): 254762 ms
Total Talk Time (CUSTOMER): 255592 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/d93cc4b3-5f85-4de3-9c62-aea166d99963_20250210T19:38_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] This is [PII] calling from provider's office and looking on a claim status.
[AGENT][NEUTRAL] OK, I can verify claim status for you and your name is again?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII] OK. And what is the policy number?
[CUSTOMER][NEUTRAL] It's 1154265 ML 5.
[AGENT][NEUTRAL] OK, thank you. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] OK, and verify the patient's name, date of birth.
[CUSTOMER][NEUTRAL] Yeah, the patient's name is [PII].
[CUSTOMER][NEUTRAL] [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] OK, and what was the date of service and amount of the charge you're calling about?
[CUSTOMER][NEUTRAL] It's [PII] for $511 even.
[AGENT][NEUTRAL] OK, and you're calling from?
[CUSTOMER][NEUTRAL] Integrated dermatology of South Miami.
[AGENT][NEUTRAL] OK. I'm showing that claim processes office visits are not covered, nor procedures performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK. May I know the received and processed date?
[AGENT][NEUTRAL] Sure, the claim was received on [PII], processed on [PII].
[CUSTOMER][NEUTRAL] OK. And uh actually, the claim has uh 3 procedure codes. What about the other two procedure codes?
[AGENT][NEUTRAL] They process as service not covered when performed at the doctor's office or clinic.
[CUSTOMER][NEUTRAL] Only the office visit is not covered under the patient's plan.
[AGENT][NEUTRAL] Correct, because the policy doesn't cover office visits nor procedures in office, only covers for outpatient or in hospital.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. And uh we have the the procedure code 11104 and 11105 as well.
[AGENT][NEUTRAL] I understand those were processes service not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEGATIVE] So, it also got uh denied as not covered under the patient's plan.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. One moment.
[CUSTOMER][NEUTRAL] When are the patients planning?
[AGENT][NEUTRAL] Medlink.
[CUSTOMER][NEUTRAL] OK. But actually for meddling, they will cover uh on that procedure codes uh with
[CUSTOMER][NEUTRAL] Excluding the office visit.
[AGENT][NEUTRAL] Not with this patient's policy. This patient's policy he has with our company or they have with our company does not cover procedures performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] We have got the
[CUSTOMER][NEUTRAL] Uh, clinic, all the procedure. So it's a patient responsibility?
[AGENT][NEUTRAL] Uh, we can't give patient responsibility. We can only verify how the claim was processed and denied.
[CUSTOMER][NEUTRAL] OK. May I have the claim number?
[AGENT][NEUTRAL] Sure. Claim number is 3557675.
[CUSTOMER][NEUTRAL] 355-7675.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. One moment.
[CUSTOMER][NEUTRAL] OK. Can you fax me the EOB?
[AGENT][NEUTRAL] We do have an online service center where providers can check claim status as well as print out the EOB. That site is at [PII].
[CUSTOMER][NEUTRAL] Actually we don't have access for this portal.
[AGENT][NEUTRAL] If you have access to the internet, you can get onto the site.
[CUSTOMER][NEUTRAL] So you can't contact the your.
[AGENT][NEUTRAL] As I said, we do have an online service center. If you need assistance with setting up, I can assist you with that.
[CUSTOMER][NEUTRAL] OK. I have 2 more patients to verify. Can you help me?
[AGENT][NEUTRAL] Sure. What's that next policy number?
[CUSTOMER][NEUTRAL] And call reference number will be the same for the entire call?
[AGENT][NEUTRAL] Sure, we don't give reference numbers. If you like, you may use my name in today's date.
[CUSTOMER][NEUTRAL] Can you spell your name for me?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So your name and today's status call reference.
[AGENT][NEUTRAL] You can use my name at today's date as a call reference.
[CUSTOMER][NEUTRAL] OK. And the next member ID is 02.
[CUSTOMER][NEUTRAL] 507926 ML 8.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, and verify the patient's name, date of birth.
[CUSTOMER][NEUTRAL] Yeah, one moment.
[CUSTOMER][NEUTRAL] The patient's name is
[CUSTOMER][NEUTRAL] You are then. [PII]. Date of birth [PII].
[AGENT][NEUTRAL] OK, data service amount of the charge.
[CUSTOMER][NEUTRAL] [PII], sorry, [PII] for $410 even.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK. And the name of that provider's office?
[CUSTOMER][NEUTRAL] Integrated dermatology of South Miami.
[AGENT][NEUTRAL] OK, and sure that claim was also processed and office visits are not covered, nor procedures performed at a doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK. May I know the receive and deny date?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Uh, the claim was received on
[AGENT][NEUTRAL] [PII] process on [PII].
[CUSTOMER][NEUTRAL] OK. So for this patient also, other than office visit 17,110 also got denied that's not covered?
[AGENT][NEUTRAL] Yes, a service not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But usually, we will not get only the payment for the procedure code office visit procedure code. Other than the surgery procedure code like 17,110, we will get the payment.
[AGENT][NEUTRAL] No, with this policy, if it's a procedure that is performed in a doctor's office or clinic, it is not covered.
[CUSTOMER][NEUTRAL] OK, may I have the claim number?
[AGENT][NEUTRAL] 3555645. I mean, I'm sorry, 3555625.
[CUSTOMER][NEUTRAL] 3555625
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] And I have one more patient.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK, and what is that last policy number?
[CUSTOMER][NEUTRAL] It's 1659386.
[AGENT][NEUTRAL] OK, and patient's name, date of birth?
[CUSTOMER][NEUTRAL] Yeah, the patient's name is
[CUSTOMER][NEUTRAL] [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Data service and amount of the charge.
[CUSTOMER][NEUTRAL] Date of service, [PII] for $150 even.
[AGENT][NEUTRAL] And is this for the same provider?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] I'm showing that claim process is benefits payable only if the major medical provides benefits.
[AGENT][NEUTRAL] Per the explanation of benefits, it does not show the primary applied any amounts towards deductible, co-pay, or co-insurance, so it is not covered under the policy.
[CUSTOMER][NEUTRAL] OK. But uh I have, uh, we have actually called previously and got the payment information.
[AGENT][NEUTRAL] What payment information because I'm not showing that it was paid. Do you have a claim number and or check number?
[CUSTOMER][NEUTRAL] For this uh
[CUSTOMER][NEUTRAL] Yeah, the claim number is 3530346.
[AGENT][NEUTRAL] And a check number?
[CUSTOMER][NEUTRAL] 2013899.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK, yeah, I show a check was mailed in the amount of $50.
[CUSTOMER][NEUTRAL] $50. OK. Actually, uh, the primary has, uh, uh, the patient responsibility of $60.
[AGENT][NEUTRAL] Uh-huh, but for the patient's policy, the max payable is 50, so we paid $50.
[CUSTOMER][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] So for the um for the uh for the date of service, you can only pay $50 for this patient.
[AGENT][NEUTRAL] That's the max benefit payable.
[CUSTOMER][NEUTRAL] OK. One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, um, balance $10 is the patient responsibility or a write-off.
[AGENT][NEUTRAL] We can't get, we can't give patient responsibility. We can only verify how the claim was processed and this claim processed and paid $50 which is the benefit max.
[AGENT][NEUTRAL] You have to contact the patient of any remaining balance.
[CUSTOMER][NEUTRAL] OK. May I know the um check issued and clear date?
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Check issued [PII], cleared on [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. Thank you.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So much.
[CUSTOMER][NEUTRAL] And the call reference will be your name and today's date.
[AGENT][NEUTRAL] Correct. You can use my name in today's date. And is there anything else, Ms. [PII] I can assist you with today?
[CUSTOMER][POSITIVE] No, that's all for today. Thank you for asking.
[AGENT][POSITIVE] You're welcome. Thank you for calling APL. Have a great day.
[CUSTOMER][POSITIVE] You too as well. Thank you. Bye.
[AGENT][NEUTRAL] Bye.