AccountId: 011433970860
ContactId: f13641e8-e99a-4378-945f-f0452fa00a6e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1007239 ms
Total Talk Time (AGENT): 467684 ms
Total Talk Time (CUSTOMER): 182555 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/f13641e8-e99a-4378-945f-f0452fa00a6e_20250109T15:55_UTC.wav
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[AGENT][POSITIVE] Good Morning, thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, I am needing help trying to get on my online account so I can look at claims to me.
[AGENT][POSITIVE] Well, it would be my pleasure to assist you this morning. Do you happen to have your policy number available?
[CUSTOMER][NEUTRAL] Yes, it is 01792125.
[AGENT][NEUTRAL] And can you verify your name and date of birth, please, ma'am?
[CUSTOMER][NEUTRAL] It is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you. And what about your current mailing address?
[CUSTOMER][NEUTRAL] Uh, it is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] All right, perfect. And what is your callback number and email?
[CUSTOMER][NEUTRAL] Callback number is [PII].
[CUSTOMER][NEUTRAL] And you said what else? I'm sorry.
[AGENT][NEUTRAL] Your email address?
[CUSTOMER][NEUTRAL] It should be [PII].
[AGENT][NEUTRAL] All right. Ms. [PII], thank you for that verification. I do see that you have an active online account.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] And your username is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And how and I should be able to get like a reset.
[AGENT][NEUTRAL] Absolutely I can't provide your password is it you know your password is protected, so I can't see that but you can reset that password.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Sweet, OK, and I can you also help me with claims?
[AGENT][POSITIVE] I'd be happy to. Yes, ma'am. It would be my pleasure to assist you with claims as well. Is this a claim for yourself or one of your dependents?
[CUSTOMER][NEUTRAL] Or no.
[CUSTOMER][NEUTRAL] Dependent.
[AGENT][NEUTRAL] And which dependent?
[CUSTOMER][NEUTRAL] It's uh [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is the data service for [PII]?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] I'm sorry, I'm lying to you. It's the day the service is [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Bear with me just one second.
[AGENT][NEUTRAL] Is this for the amount of $2410.68?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Looks like we've received that claim several times. Let me check on this for you one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And if you're looking online.
[AGENT][NEUTRAL] Um, there is an original claim, claim number 3444134. It's the original claim submission for BA Healthcare Services.
[CUSTOMER][NEUTRAL] You said 344.
[AGENT][NEUTRAL] 4134.
[CUSTOMER][NEUTRAL] 344-31
[CUSTOMER][NEUTRAL] 4
[AGENT][NEUTRAL] Um, 344-4134. It's a lot of threes and fours.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So it's 344-4134.
[AGENT][NEUTRAL] And if you click on that claim number it'll give you the original claim decision.
[CUSTOMER][NEUTRAL] So what is going on because they used to get paid at one point in time.
[AGENT][NEUTRAL] So, according to the um
[AGENT][NEUTRAL] Item, the the procedure code, the A 9276, that is a disposable.
[AGENT][NEUTRAL] Sensor and because of the guidelines of the policy, the policy does not, um, if it's disposable.
[AGENT][NEUTRAL] It is not considered a payable, durable medical equipment benefit.
[CUSTOMER][NEUTRAL] OK, but I don't understand because they would pay him they they paid him for 2023, didn't they?
[AGENT][NEUTRAL] Let me check and see. I'm looking up with that code.
[AGENT][NEGATIVE] I don't see any payments. I'm going back to [PII]. I don't see any payments for that code.
[CUSTOMER][NEGATIVE] So you said you're saying that y'all never paid anything for Byron for because I could have sworn y'all did.
[AGENT][NEGATIVE] Not for this, not for this procedure code. We might have paid for another code that was in fact a covered.
[AGENT][NEUTRAL] Um, durable medical equipment. Let me just take a quick look.
[AGENT][NEUTRAL] Let me go through these claims real quick.
[AGENT][NEUTRAL] Now there is a code that they did.
[AGENT][NEUTRAL] And this is back in 23. Let's see what this is.
[AGENT][NEUTRAL] For the transmitter, we did pay that claim.
[AGENT][NEUTRAL] And that is claim number 341.
[AGENT][NEUTRAL] 5414.
[CUSTOMER][NEUTRAL] 341.
[AGENT][NEUTRAL] 15414
[AGENT][NEUTRAL] And it does
[CUSTOMER][NEUTRAL] And what data service is that?
[AGENT][NEUTRAL] That is data service too.
[AGENT][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] OK, [PII].
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And if you click on your policy number, it will download your policy documents and you can view the definition of covered durable medical equipment.
[CUSTOMER][NEUTRAL] Well, but the thing of it is.
[CUSTOMER][NEUTRAL] You said February.
[AGENT][NEUTRAL] And we also paid.
[AGENT][NEUTRAL] Excuse me, paid them $1,019.44 for that same procedure code for data service 842422.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEGATIVE] So it's the same thing that she's getting. That's what I'm not understanding.
[AGENT][POSITIVE] And I can give you
[AGENT][NEUTRAL] So that
[AGENT][NEUTRAL] That the medical equipment code A 9276 is a disposable unit.
[CUSTOMER][NEUTRAL] So, uh, uh, what I'm trying to figure out is, are they coding it different?
[AGENT][NEUTRAL] So for the actual.
[AGENT][NEUTRAL] piece of equipment, they have what's called procedure codes.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Let me see if this is on the EOB. Let me pull up the EOB so you can see that.
[AGENT][NEUTRAL] See if you can see what codes they're filing for.
[AGENT][NEUTRAL] Give me just a second.
[AGENT][NEUTRAL] It's just taking my computer a moment, so if you click on the pol the any of those claim numbers.
[AGENT][NEUTRAL] Hm
[AGENT][NEUTRAL] Under if you pull up, it will pull up your EOB or explanation of benefits.
[AGENT][NEUTRAL] And that is going to give you the date of service.
[AGENT][NEUTRAL] Um, who the provider was the buyer Healthcare services.
[AGENT][NEUTRAL] And then 12345 on the sixth column over is the procedure code and that A 9276 is non-covered.
[AGENT][NEUTRAL] And then on the 2nd page,
[AGENT][NEUTRAL] Of your explanation of benefits will give the reason.
[CUSTOMER][NEUTRAL] Right, so what I'm saying is if they paid the one back in [PII].
[CUSTOMER][NEGATIVE] I don't understand why they ain't paying any others because it's the same she's receiving the same exact thing.
[AGENT][NEUTRAL] They build for a different procedure code.
[AGENT][NEUTRAL] Let me go back to that 2023 claim.
[CUSTOMER][NEUTRAL] So I'm trying to find it on here.
[CUSTOMER][NEUTRAL] But I'm not
[AGENT][POSITIVE] No, you're asking really good questions.
[AGENT][NEUTRAL] Getting back to that February.
[AGENT][NEUTRAL] So the procedure code that they billed that we paid was the A 9277.
[AGENT][NEUTRAL] That piece of, that's a transmitter. It's not disposable, and it does fall within the guidelines of the policy for covered durable medical equipment. That's why we're able to
[AGENT][NEUTRAL] Process and pay that 9277.
[AGENT][NEUTRAL] Now, the one that's been denied um on her history is the A 9276.
[AGENT][NEUTRAL] And that is a disposable piece of durable medical equipment, which does not meet the definition of covered durable medical equipment, according to the guidelines of the policy.
[AGENT][NEUTRAL] So it just depends on the actual.
[AGENT][NEUTRAL] Piece of durable medical equipment and the code that they bill.
[CUSTOMER][NEUTRAL] I back.
[AGENT][NEUTRAL] So for the sensor, it is disposable, and that is why that is not covered.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So I'm just trying to see why they started doing it different.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's my question. I'm like because.
[CUSTOMER][NEUTRAL] They've all paid they were paying all the way, uh, I mean they paid 23, all of 2023 for it.
[AGENT][NEGATIVE] Only for that um A 9277, the A9276 was not covered in [PII] for the same reason. It does not.
[AGENT][NEUTRAL] Meet the definition of covered durable medical equipment. Now, the other code that they charge, the A9277 is not disposable, therefore, it can be considered for benefits.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] Looks like
[AGENT][NEUTRAL] I was just checking looks like those are the two main codes that they're billing for.
[AGENT][NEUTRAL] There are other ones, but those are the, looks like to be the main.
[AGENT][NEUTRAL] In [PII], in 2024, there are other codes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now let me check because there was one on June.
[AGENT][NEUTRAL] 26 that we were requesting the primary EOB. Let me see if we received that.
[AGENT][NEUTRAL] We did not
[AGENT][NEUTRAL] There was a claim on 9-19-2024.
[AGENT][NEUTRAL] Under claim number 351.
[AGENT][NEUTRAL] 65.
[CUSTOMER][NEUTRAL] What data service is that?
[AGENT][NEUTRAL] 02 this is on 9-19-24. Now this is from Edge Park.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] For [PII].
[AGENT][NEUTRAL] I was just going through these claims to see.
[AGENT][NEGATIVE] Now on this one they did not send us we requested the primary explanation of benefits on this claim and we have not received that yet.
[CUSTOMER][NEUTRAL] OK, well.
[AGENT][NEUTRAL] So that one we haven't completed the processing we're just waiting for that additional information.
[AGENT][NEUTRAL] It's hard to understand. I know there's a lot of.
[AGENT][NEUTRAL] Procedure codes and things for durable medical equipment.
[CUSTOMER][NEUTRAL] So I'm trying to see how
[CUSTOMER][NEUTRAL] So you're saying the CPT code that they're using, is that is that what you're calling the 9277, is it a CPT code?
[AGENT][NEUTRAL] That's right. That's a CPT, which means a procedure code.
[CUSTOMER][NEUTRAL] Which I don't think.
[CUSTOMER][NEUTRAL] And see when I look at these claims, OK, alright, um.
[CUSTOMER][NEUTRAL] I will give them a call and see what's going on, OK.
[AGENT][POSITIVE] Yes, ma'am. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][POSITIVE] No, that should be it. Thank you.
[AGENT][POSITIVE] Well, it has been such a pleasure to assist you, Ms. [PII], and if you need further assistance, don't hesitate to give us a call. If you click on your policy number, you can view the definition of durable medical equipment and what is covered under your policy.
[CUSTOMER][POSITIVE] OK, sounds great thank you.
[AGENT][POSITIVE] And thank you for calling APL. I hope you have a wonderful day.
[CUSTOMER][POSITIVE] You too, thank you.
[AGENT][POSITIVE] Thank you. Bye-bye.