AccountId: 011433970860
ContactId: f6c270a9-bd7a-4c41-a570-f705d549defe
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 443510 ms
Total Talk Time (AGENT): 150377 ms
Total Talk Time (CUSTOMER): 196896 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/12/f6c270a9-bd7a-4c41-a570-f705d549defe_20250212T18:36_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, very good afternoon. This is [PII]. I'm calling from doctor's billing office. I'm looking for denial claims.
[AGENT][NEUTRAL] Sure, I can look at a claim for you. uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure. Uh, which is [PII]. It's a direct line. Also, I missed your good name. Could you please spell out your name?
[AGENT][NEUTRAL] Yeah, it's [PII]
[AGENT][NEUTRAL] And then did you have that policy number? Yeah.
[CUSTOMER][POSITIVE] [PII], thank you.
[CUSTOMER][NEUTRAL] Yes. Yes, I do, which is 021-73249.
[AGENT][NEUTRAL] OK, thank you and what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] Uh, patient's first name is [PII]. The last name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that [PII] and you said we were checking on uh we're needing clarification for a denial, is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. Yes.
[AGENT][NEUTRAL] OK, did you have that claim number?
[CUSTOMER][NEUTRAL] Yes, I do, which is 353.
[CUSTOMER][NEUTRAL] 5843.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, this was for uh Virginia Cancer Institute.
[CUSTOMER][POSITIVE] Yes, you got it.
[AGENT][NEUTRAL] OK, OK, so I did find this claim, uh, so we were unable to pay a benefit as the services are not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. So as the patients plan, the uh services for the non-covered or uh
[CUSTOMER][NEGATIVE] Generally, the, uh, when the patient was visit to uh doctor's office, the service is not covered.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, so it's a patient responsibility, right?
[AGENT][NEUTRAL] We do not say what is patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] OK. Let me check that. Is there any previous payment uh received for this patient? Just, just give me a couple of seconds here.
[AGENT][NEUTRAL] OK, sure.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK. So as you mentioned that the particular uh procedure or the particular service uh was rendered in office, office, so that's the reason the payment uh the service was not covered, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, because, uh, we just received payment for office code in the place of service 11, so it doesn't matter.
[AGENT][NEUTRAL] Say that again, I'm sorry.
[CUSTOMER][NEUTRAL] I mean, um, but the same patient, uh, we have received payment for date of service [PII]. We billed with the procedure code 99214 with uh place of service 11. So we received payment for that.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] So, as you mentioned that the particular procedure, mhm.
[AGENT][NEUTRAL] You did say that was I'm sorry, procedure code 99214.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so that is a different procedure code than any on this particular claim, so it is possible that that procedure is covered in office. These particular procedures are not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so the uh
[CUSTOMER][NEUTRAL] One moment here.
[CUSTOMER][NEUTRAL] OK, so the admin code and the non-chemo drug code was non-covered when the service was rendered in office. So got you. And I need an explanation of benefits because when we have received the explanation of benefits, there is no reason mentioned on it. So if you uh
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure, I can get that sent to you. Do you have a fax number?
[CUSTOMER][POSITIVE] Thank you. Yes, I do.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Which is 8, which is [PII].
[AGENT][NEUTRAL] OK, I'm going to read that back, make sure I heard that correctly. That was [PII].
[CUSTOMER][NEUTRAL] Yes, and to make an attention to [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alrighty, I will get that sent to you right now. I should get it here in maybe 1015 minutes depending on how busy your machine is. Was there anything else I can help you with, [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, I have a last question, um, because, uh, we just, uh, informed one of your previous representative because, uh, we received a, a payment from, uh, primary carrier and, uh, but the secondary career did not accept him for this reason. So we have filed an appeal through fax. Uh, so just take a look on it, whether the fax was received or not as of today.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You said that fax today you said?
[CUSTOMER][NEUTRAL] Yes, we submitted on [PII]. We filed an appeal with complete medical records for reconsideration.
[CUSTOMER][NEUTRAL] I have a transaction ID, so.
[AGENT][NEUTRAL] But I'm sorry, you did say that that was sent today though.
[CUSTOMER][NEUTRAL] No, no. We uh sent on [PII].
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] I see. Sorry about that. OK, give me just a moment, let me see if that was received.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure, sure.
[AGENT][NEUTRAL] OK, it looks like it just registered as a duplicate um so for appeals [PII], we do have to have a letter included with that that states that it is indeed an appeal and of course why.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK. So, as you mentioned, there is a specific uh cover sheet for an Apple, right? So what will be the cover letter when uh.
[AGENT][NEUTRAL] Yes, it does have to have that. Oh, it doesn't have to be a lot just stating that of course it is for an appeal.
[AGENT][NEUTRAL] Otherwise it would just be registered as a duplicate claim.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] OK, so I, that I can get you know Google that application form, I mean the cover letter.
[AGENT][NEUTRAL] You can send that letter however you'd like, sure, um, that's that's perfectly fine we just need something stating that it is for an appeal.
[CUSTOMER][NEUTRAL] OK. So while uh sending the explanation of benefits, so just uh attach the appeal cover sheet along with it.
[AGENT][POSITIVE] Correct, yes, we do have to have something showing that it is an appeal.
[CUSTOMER][NEUTRAL] OK. OK, got you. So, so when can I expect the explanation benefit as you said uh 20 to 30 minutes?
[AGENT][NEUTRAL] Um, no, I shouldn't take quite that long. I did just send it, um, so I would say no longer than about 10-15 minutes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, perfect. So that's all I need information, [PII]. So what is the reference number for this conversation?
[AGENT][NEUTRAL] Reference number would just be my first name, last initial, and today's date and so my last initial is [PII] Was there anything else I could help you with, [PII]?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] So, that's it. Thank you. Have a great day. Bye-bye.
[AGENT][POSITIVE] OK, yeah, of course you too thank you bye bye.
[CUSTOMER][NEUTRAL] Bye.