AccountId: 011433970860
ContactId: e76a57f8-8c38-43ae-a9ea-d7d0a16b0c81
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 526140 ms
Total Talk Time (AGENT): 239619 ms
Total Talk Time (CUSTOMER): 225050 ms
Interruptions: 4
Overall Sentiment: AGENT=1.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/21/e76a57f8-8c38-43ae-a9ea-d7d0a16b0c81_20250321T18:49_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] Yeah, this is [PII] calling from Bra Medical Center. Can you hear my voice?
[AGENT][POSITIVE] I'm doing, I, it's my pleasure to assist you. How are you doing today?
[CUSTOMER][POSITIVE] I'm doing very well. What about you?
[AGENT][POSITIVE] I'm doing good, thank you. Do you mind repeating your name, please?
[CUSTOMER][NEUTRAL] Yeah, definitely. Let me spell it for you. That is [PII] sure. Did you get that now?
[AGENT][POSITIVE] Thank you, [PII]. And what is a good call back number?
[CUSTOMER][NEUTRAL] OK, let me tell you the callback number as well. That is [PII].
[AGENT][NEUTRAL] [PII], OK, [PII]. What were the last four numbers? [PII]?
[CUSTOMER][NEUTRAL] Let let me tell you, let me tell you from the beginning. It's [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you, [PII].
[AGENT][POSITIVE] And how can I help you today?
[CUSTOMER][NEUTRAL] Actually, I slip your name. Could you please?
[AGENT][NEUTRAL] Sure. My name is.
[CUSTOMER][POSITIVE] OK, thank you so much. Sorry for the interruption. Could you please spell your name?
[AGENT][NEUTRAL] Sure, my name is [PII] and the first initial of my last name is [PII].
[CUSTOMER][NEUTRAL] Thank you so much, [PII], for confirming your name. OK. So I just wanted to help in a claim. Actually, there was no any UV, so I'm not able to fetch the details why that claim has been that. I just wanted to know the claim status. Could you please help me with the claim?
[AGENT][NEUTRAL] It would be
[AGENT][POSITIVE] It would be my pleasure, [PII]. And do you happen to have a claim number or the patient's policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, let me tell you the patient details. As I don't have a claim number, as I told you, there is no any UV. So should I tell you the member ID first?
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] OK, the member ID is 01611858.
[CUSTOMER][NEUTRAL] M for Mary, L for Lima.
[AGENT][NEUTRAL] Thank you, [PII]. And what is the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] The patient name is [PII] and the date of birth is [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] And [PII], what is that data service?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The date of service is [PII].
[CUSTOMER][NEUTRAL] And the real amount is $3750 even.
[AGENT][NEUTRAL] All right, thank you and what is the name of the facility?
[CUSTOMER][NEUTRAL] The facility name is Bram Healthcare Centers.
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] And I can help you with that claim information [PII]. We received that claim on [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim was processed on December, I'm sorry, on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And that claim was denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the denial reason is because.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Bear with me.
[AGENT][NEGATIVE] The item that was billed does not meet the policy definition of durable medical equipment, therefore, it is noncovered.
[CUSTOMER][NEUTRAL] OK, so that is denied for the non-covered, right?
[AGENT][NEUTRAL] That's right for that DME now we do cover DME but it has to meet the definition.
[AGENT][NEGATIVE] Um, it has to be able to withstand repeated use. It cannot be a disposable item.
[AGENT][NEUTRAL] And I believe that that one is a disposable. Let me check.
[AGENT][NEUTRAL] And that would be the reason for the denial.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But it should not be denied because, OK, let me also check because I think as much as I know that is not disposable because.
[AGENT][NEGATIVE] Yeah, that is not disposable.
[CUSTOMER][NEUTRAL] It was
[CUSTOMER][NEUTRAL] OK, OK. You also check in your system and let me check also.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because that is the procedure code 4239 and that is, I think Dicom.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] That is Dexcom CGM supply G6 season supply, I think that is a sensor actually, so that is not disposable I think.
[AGENT][NEUTRAL] No, it is not disposable. I apologize.
[CUSTOMER][NEUTRAL] Could you please send this back for?
[AGENT][NEUTRAL] Uh, bear with me, I'm getting that claim pulled up if you'll bear with me just one second, let me check and see that also has to be covered by the primary insurance, so let me look at that EOB and see if it was covered.
[AGENT][NEUTRAL] Give me just
[CUSTOMER][NEUTRAL] Yeah, because it was some amount has been paid on back primary as well, and after that primary has put some amount on coins and they check.
[CUSTOMER][NEUTRAL] After that, it was sent to you.
[AGENT][NEUTRAL] And let's see it.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Has to be used as a to serve a medical purpose with respect to treatment.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Of an inpatient cover charge or outpatient cover charge.
[AGENT][NEGATIVE] And it is not useful to a person in the absence of a sickness or injury.
[AGENT][NEUTRAL] And is not implantable and is covered by the primary.
[CUSTOMER][NEUTRAL] Mm OK.
[AGENT][NEUTRAL] So they're saying that it.
[CUSTOMER][NEUTRAL] Mm. OK, and family also.
[CUSTOMER][NEUTRAL] Paid actually. Can you see that UV of primary?
[AGENT][NEUTRAL] I can, and there was nothing applied to the deductible co-pay or co-insurance.
[CUSTOMER][NEUTRAL] Yeah, it was in a coins I think $195 has been put on coins by primary. They paid $780 and the rest of the amount of $195 they put on a coins. After that, it was sent to you.
[AGENT][NEUTRAL] OK, so that may be that that's why it was denied on this EOB that we have.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] It does not show the deductible copay or co-insurance amount applied by United Healthcare.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] All we have is the build amount paid amount.
[CUSTOMER][POSITIVE] But in the UV I can see it was a quite fine.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Not an issue. So what [PII], could you please do one thing if
[CUSTOMER][NEUTRAL] You can review this claim once and let your team check.
[AGENT][NEUTRAL] Yeah, so that's what I was doing. I was looking at the EOB that we received.
[AGENT][NEUTRAL] And the EOB only shows that United paid $780.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] With the adjustment amount of $2970. So there was nothing applied to the patient's deductible, according to the EOB we have on file.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Do you happen to have an updated EOB showing what was applied to deductible, co-pay, or co-insurance?
[CUSTOMER][NEUTRAL] But it was
[CUSTOMER][NEUTRAL] Yeah, actually, it was not, it was not applied on deductible. What is uh, it was applied on a coinsurance, coins.
[AGENT][NEUTRAL] Yeah, I don't see that on the EOB either so if you have an EOB with an amount.
[AGENT][NEUTRAL] Applied to the deductible, co-pay or co-insurance, that updated EOB can be resubmitted for reconsideration.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] Not an issue. I'll try to do it from my end. Could you please tell me the calling reference number?
[AGENT][NEUTRAL] The call reference number is my name and today's date.
[AGENT][NEUTRAL] And [PII], do you need that claim number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, you can provide me the number please.
[AGENT][NEUTRAL] The claim number is 355.
[AGENT][NEUTRAL] 44447.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much, [PII]. It was really nice talking to you. Have a great day ahead. Thank you so much. Bye for now.
[AGENT][POSITIVE] It's been my pleasure.
[AGENT][POSITIVE] It's been my pleasure to assist you with that claim informa.