AccountId: 011433970860
ContactId: f6f9c344-08c4-4add-a388-96b73ec55d39
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1129349 ms
Total Talk Time (AGENT): 203100 ms
Total Talk Time (CUSTOMER): 280610 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/01/f6f9c344-08c4-4add-a388-96b73ec55d39_20250501T20:14_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling from Multi-care Health System, and I'm calling to uh check the status of a claim.
[AGENT][NEUTRAL] OK, and I can help you with claim status. Do you have a good callback number, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And do you have the policy number of the patient?
[CUSTOMER][NEUTRAL] Um, I do. It is.
[CUSTOMER][NEUTRAL] 025650007.
[AGENT][NEUTRAL] And patient name and date of birth?
[CUSTOMER][NEUTRAL] This is uh [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] And what was that date of service and bill charges?
[CUSTOMER][NEUTRAL] Um, I have a few. First one is [PII] for $480.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] OK, looks like the original, I think we received it twice, um, received.
[AGENT][NEUTRAL] And I'm sorry, what was the bill charges again? Sorry about that.
[CUSTOMER][NEUTRAL] $480.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, was received 126 25 and that was processed 12925.
[AGENT][NEUTRAL] What the
[AGENT][NEUTRAL] Previously denied policy lapsed, reinstated. OK, I'm trying to read what's going on here.
[AGENT][NEUTRAL] Uh, reinstated with see new mail for corrected claim.
[CUSTOMER][NEUTRAL] I got it.
[AGENT][NEUTRAL] Will they process the new mail number for corrective claim, OK.
[AGENT][NEUTRAL] OK. Mhm.
[AGENT][NEGATIVE] Uh, it looks like we had denied the claim, and this was received on.
[AGENT][NEUTRAL] 129 25 and then process same day.
[AGENT][NEUTRAL] So this is a limited hospital indemnity program or plan.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Outpatient treatment provides an indemnity amount when a covered person receives treatment in an ER, urgent care, physician's office, um, or for physical or physical or occupational therapy.
[AGENT][NEUTRAL] Uh, treatment
[CUSTOMER][NEUTRAL] OK, so this is an office visit in a doctor's office. It looks like it's in cancer care.
[AGENT][NEUTRAL] Uh, let's see, let me pull up what the the claim we received because it looks like it was 99222.
[AGENT][NEUTRAL] Which is like an outpatient.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh, I'm looking at a 99215.
[CUSTOMER][NEUTRAL] For $480 for Doctor [PII].
[AGENT][NEUTRAL] Mm.
[AGENT][NEGATIVE] Oh, you know what, I'm on the wrong patient. That would probably
[AGENT][POSITIVE] That would probably help to be on the right patient. She was. I'm so sorry.
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] And they're done that.
[AGENT][NEUTRAL] Oh my goodness. [PII], right?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Start over. I'm so sorry about that.
[CUSTOMER][POSITIVE] Oh, no worries.
[AGENT][NEUTRAL] OK, so let's see what we have here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] The original.
[AGENT][NEUTRAL] OK, this denied for the same reason, but let me, let me pull up the claim, um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So sorry, my system is really slow. OK, let's see.
[CUSTOMER][POSITIVE] Oh, no worries.
[AGENT][NEUTRAL] OK, it's pulling up the claim, just checking what we, OK, so I see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, the place of service on the CMS 1500 at 22.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Place of service.
[CUSTOMER][NEUTRAL] Yes, it does say 22.
[CUSTOMER][NEUTRAL] So that's outpatient.
[AGENT][NEUTRAL] Yeah, so for this policy,
[CUSTOMER][NEUTRAL] Must be at our regional care.
[AGENT][NEGATIVE] Um, because of that place of service, that's what made the denial.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Place the service 20 so if this was in an office visit, it would probably be paid?
[AGENT][NEUTRAL] Um, correct, I believe they have, uh, let's see, usually have like a max of like 4 visits.
[CUSTOMER][NEUTRAL] Yeah, but this is in December, so is that gonna matter? I mean, has she maxed her office visits yet?
[AGENT][NEUTRAL] Um, let me see.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Let me check the uh accumulators. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, let's see, so she used 2 of the 4.
[CUSTOMER][NEUTRAL] OK, so she still has a couple left for [PII] or [PII].
[AGENT][NEUTRAL] Yes, based on
[AGENT][NEUTRAL] Yeah, right, right at this moment, yes, she does.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I'll see.
[CUSTOMER][NEUTRAL] Uh, if this was coded correctly, I can send it back, um.
[CUSTOMER][NEUTRAL] OK, now do we have an EOB on that?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] 91
[CUSTOMER][NEGATIVE] And that must have taken it back, yep, and then denied it for.
[CUSTOMER][NEUTRAL] OK, can I have you check um.
[CUSTOMER][NEUTRAL] A different data service for her?
[AGENT][NEUTRAL] Sure, what was that date?
[CUSTOMER][NEUTRAL] I've got like 4 others. The next one is [PII] for $566.
[CUSTOMER][NEUTRAL] And that's for radiation.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] Looks like we got it 3 times. Let me see.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] again and.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Uh, looks like this one, outpatient treatment, only covered in emergency room, urgent care, physician's office, physical or occupational therapy.
[AGENT][NEUTRAL] Treatment in outpatient hospital not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEGATIVE] Again, place the service 22 not covered.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] And that is patient responsibility for, OK, that one.
[CUSTOMER][NEUTRAL] OK, and then how about um I've got like 4 more dates of service.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The next one is [PII].
[CUSTOMER][NEUTRAL] For $490.
[CUSTOMER][NEUTRAL] Same thing, it was place of service 22.
[CUSTOMER][NEUTRAL] And I'm not sure why that place of service either.
[AGENT][NEGATIVE] Uh, yes, same denial.
[CUSTOMER][NEUTRAL] OK, so denied.
[CUSTOMER][NEUTRAL] service. Let's see if I have, and I don't have an EOB on file for that one. Can you fax me a copy for our records?
[AGENT][NEUTRAL] Uh, for which one?
[CUSTOMER][NEUTRAL] And it looks like she for [PII].
[CUSTOMER][NEUTRAL] For 490.
[CUSTOMER][NEUTRAL] Looks like she has a secondary.
[CUSTOMER][NEUTRAL] As a Medicaid plan.
[AGENT][NEUTRAL] Let me get that.
[AGENT][NEUTRAL] And what is your fax number?
[CUSTOMER][NEUTRAL] [PII], that's my work phone, sorry uh [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, I'll get that faxed over.
[CUSTOMER][NEUTRAL] OK, and the next day of service is [PII].
[CUSTOMER][NEUTRAL] For $899.
[AGENT][NEGATIVE] Uh, same denial.
[CUSTOMER][NEUTRAL] And that was again, uh, not a covered benefit in this place of service or just not a covered benefit?
[AGENT][NEGATIVE] Uh, not a covered benefit in the place of service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And can you fax me a copy of that EOB too? I don't know why we don't have these.
[AGENT][NEUTRAL] Uh, sure.
[AGENT][NEUTRAL] OK. And then the next one.
[CUSTOMER][NEUTRAL] Is [PII].
[CUSTOMER][NEUTRAL] Um, for 133.
[CUSTOMER][NEUTRAL] That is also.
[CUSTOMER][NEUTRAL] Yeah, I don't have that EOP either.
[AGENT][MIXED] OK, calendar year maximum for the diagnostic service was met.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] And that was done.
[CUSTOMER][NEUTRAL] Calendar year max for what?
[AGENT][NEUTRAL] On diagnostic service.
[CUSTOMER][NEUTRAL] For this particular sir?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And can you fax that EOB? We don't have that one either.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, the next one is [PII] also for 133, same charge.
[AGENT][NEUTRAL] Uh, same denial calendar year maximum on diagnostic services met.
[CUSTOMER][NEUTRAL] For diagnostic.
[CUSTOMER][NEUTRAL] OK, and if you could fax that one too.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then I have.
[CUSTOMER][NEUTRAL] Let's see one more on 2.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] For 490.
[AGENT][NEUTRAL] Uh, that one was the place of service.
[CUSTOMER][NEUTRAL] Tonight the place of service.
[CUSTOMER][NEUTRAL] OK, and if you could fax that one as well.
[CUSTOMER][NEUTRAL] And then again I I'll send these to coding just to see I'm not sure what that outpatient is all about.
[CUSTOMER][NEUTRAL] Especially for like an office visit, but.
[CUSTOMER][NEUTRAL] At least I can say yep, it was right or it was wrong.
[AGENT][NEUTRAL] OK, yeah, and I'll get those faxed over to you. Just give me about 5 minutes.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] OK, that'd be great and [PII], do you guys use reference numbers?
[AGENT][NEUTRAL] It's just my name and today's date.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][POSITIVE] Thank you so much for your help you have a great day.
[AGENT][POSITIVE] OK, thanks for calling APLU as well. Bye-bye.
[CUSTOMER][NEUTRAL] Mhm bye bye.