AccountId: 011433970860
ContactId: f674aec0-c498-4764-8fb2-0ea7593783b7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 705080 ms
Total Talk Time (AGENT): 294278 ms
Total Talk Time (CUSTOMER): 244209 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/06/f674aec0-c498-4764-8fb2-0ea7593783b7_20250506T20:10_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, [PII], my name is [PII]. Uh, I was calling to see, uh, uh, I, I have a claim. I mean, I, I see a claim and, and it seems not to have been paid and I wanna see why, what was the reason it wasn't paid, uh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, I can look at the claim with you. Um, [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[CUSTOMER][NEUTRAL] And then the policy number, would that, no, that wouldn't be the group number, no, it would be the
[AGENT][NEUTRAL] It should say policy certification number? Yes.
[CUSTOMER][NEUTRAL] The inhospital
[CUSTOMER][NEUTRAL] The hospital benefits certification number?
[AGENT][NEUTRAL] Yes, um, I just need the numbers.
[CUSTOMER][NEUTRAL] OK. It's 0.
[CUSTOMER][NEUTRAL] 0198
[CUSTOMER][NEUTRAL] 2113 ML 7.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And I have you here. I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] [PII]. Email is [PII] and the address is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment.
[AGENT][NEUTRAL] So now, is this the claim, so there's the, the last claim that we processed it finished on [PII], is that the claim or the one before it?
[AGENT][NEUTRAL] Because
[CUSTOMER][NEUTRAL] The one, there's two claims that, that, that with the University of Miami.
[CUSTOMER][NEUTRAL] That I called, right? One that I called and I, and they told me that uh the office type that it needed to be levied. It wasn't an outpatient procedure. I told them, uh, so they, they resubmitted the claim.
[CUSTOMER][NEUTRAL] Apparently, that's, that's for the the visit on.
[CUSTOMER][NEUTRAL] It just came out this thing. That was for.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] For [PII], that's, that's the one that I'm calling about.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see if this is February.
[CUSTOMER][NEUTRAL] Yeah, the one for [PII], that one is I called before.
[CUSTOMER][NEUTRAL] And that's the one that that the office type was incorrectly clean cleaned, I guess, you know.
[AGENT][NEUTRAL] OK, I see what's happening now. OK, so these two and then now. OK. So they were both denied for the same reason, the one for November and the one for February. The um, it's not a it's not a covered loss under the plan. So there's no benefits payable.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] And it's because I, I explained to the, to, I mean, the prior person that it was, that the setting is an outpatient setting, but it's not an, it wasn't an outpatient, you know, I went to a, a gastroenterologist visit. That that's what I did, you know. And this one was a, a, a visual exam, you know. So they're not outpatient procedures, but I think.
[CUSTOMER][NEUTRAL] So I, I, so it's the same reason I guess. That's why you're, uh, you denied it, right?
[AGENT][NEUTRAL] Yes, it's for the same reason. Um, this one, the one for February though.
[AGENT][NEUTRAL] University of Miami Division of General Surgery. See it.
[AGENT][NEGATIVE] But it still has the same code, the 99213, which is an office setting. So that's why this is coming back denied because of the codes that they're putting [PII].
[AGENT][NEUTRAL] Is a place of service for the um like the in-office.
[AGENT][NEGATIVE] And so that's why they're being denied because the policy covers outpatient facilities versus the office.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] But yeah, I'm a little confused because when I go to, let's say my dermatologist, right, the policy covers me, right?
[CUSTOMER][NEUTRAL] A co-payment, my co-payment.
[CUSTOMER][NEUTRAL] So I'm, I went to a gastroenterologist here.
[CUSTOMER][NEUTRAL] And normally they, they cover me, you know.
[AGENT][NEUTRAL] So you have the office.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEGATIVE] Yeah, I'm like, why wouldn't you cover.
[CUSTOMER][NEUTRAL] A, a gastro visit, you know.
[CUSTOMER][NEUTRAL] And it covers a dermatologist visits, you know.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] So it's what's being sent in. So your primary has its own benefits and your secondary has its own benefits. So your secondary
[AGENT][NEUTRAL] Has the office treatment writer which covers the treatment that can be that's done in the office as long as it's not cosmetic. So that's why sometimes the the treatment that you received in those offices could be covered, but when they're sending in a code just for the facility, that's not going to be covered because you don't have any coverage for the facility, only the treatment in the facility.
[CUSTOMER][NEUTRAL] So in other words, do you know if that because I, because uh I sent them a message for the for the one on [PII]. I went to I went to the University of Miami and I told them, Hey, you need, you need to resubmit it and make sure that the, the office type is 11 because that's what they told me before, right?
[CUSTOMER][NEUTRAL] Do you know if they resubmitted that one or no?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, we haven't received remissions for either of those claims. Um, the next one that came in was for [PII].
[AGENT][NEUTRAL] So it was a different data service.
[CUSTOMER][NEUTRAL] [PII]th, yeah.
[CUSTOMER][NEUTRAL] Yeah, no, but the only problem that I have is with with the November visit and 117-2024 and the [PII]. and it's weird because I've been going to a to a place for for you for a number of years, you know. It's not like the first claim that from the, from the place, you know.
[CUSTOMER][NEUTRAL] Like they've been checking my eyes for like 2 years at least, you know.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] So if, if I want to talk to them again.
[CUSTOMER][NEUTRAL] Do, can you tell me what they should use what uh code they should use for the office type?
[AGENT][NEUTRAL] Hold on one moment. Let me pull up all your full benefits. Hold on one second.
[CUSTOMER][NEUTRAL] Oh, I see, yeah.
[AGENT][NEUTRAL] So, let me see what all you have. Hold on one moment.
[AGENT][NEUTRAL] OK, so your policy
[AGENT][NEUTRAL] So your policy has both. So you see how these two are denied.
[AGENT][NEUTRAL] You do have a physician office visit fee, which will help pay for the visit fee, the office, and you have a specialist office. So on top of the treatment, you also have the office visit fee rider. It'll pay $25.04 times a year for the physician's office and $50.04 times a year for the specialist office. So, let me see what you've used for 24 and 25.
[AGENT][NEUTRAL] Oh, what's 25.
[AGENT][NEUTRAL] It looks like you have one more that may be used for 2024. Um, if you'd like, I can send.
[AGENT][NEUTRAL] One of the two back, because you do have 1 more benefit.
[AGENT][NEUTRAL] For 2024.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] So I can send it back to claims for them to reprocess. I don't know that it that it will come back with a different decision, but if it was processed incorrectly and they can use this benefit, then they'll definitely reprocess it and use it, but if it was processed correctly, um, then they would just give you a call back and let you know.
[AGENT][NEUTRAL] Do you want me to send it back?
[CUSTOMER][NEUTRAL] OK, can you do that?
[CUSTOMER][NEUTRAL] Yeah, I guess so. Can you explain to them that uh
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] But I feel, I mean, they, that they should pay.
[AGENT][NEUTRAL] I'm just gonna have the, I'm gonna send them back the claims because it's the same amount, the same place and the same code, it's just a different day. So I'm gonna send them back both of the claims and um let them know that there was still one more.
[AGENT][NEUTRAL] 50 times.
[AGENT][NEUTRAL] 200.
[AGENT][NEUTRAL] Yeah, and see if this um specialist office visit fee or physician's office visit fee can be applied to one of the two or if not, um, for them to tell us, you know, if the claim was processed correctly.
[CUSTOMER][NEGATIVE] OK, that way, yeah, because they they're charging me now I owe them like $120 something like that, you know, and.
[AGENT][POSITIVE] Yes, well, I can definitely send this back and see what um they, what they come back with and I'll put for them to give you a call with an update.
[AGENT][NEUTRAL] Once they reprocess,
[CUSTOMER][POSITIVE] OK, that, that would be good.
[AGENT][NEUTRAL] Alright, and you, and you want us to give you a call on the [PII]?
[CUSTOMER][POSITIVE] That would be good.
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK, so I'm going to send them back both claims and then um see what they come back with um to let us know if you do have one more visit left for [PII] that can be applied or if this was um processed correctly.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, well, was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] No, no, no, no, that, that, that'll be all. Thank you very much.
[AGENT][POSITIVE] You're very welcome. Well, thank you for calling APL. I hope you have a good evening.
[CUSTOMER][POSITIVE] OK, you too. Thank you.
[AGENT][POSITIVE] Thank you. You're welcome. Bye bye.