AccountId: 011433970860
ContactId: fa9cde52-5594-414b-b686-eee474cc0d51
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 298420 ms
Total Talk Time (AGENT): 153731 ms
Total Talk Time (CUSTOMER): 68471 ms
Interruptions: 0
Overall Sentiment: AGENT=1.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/24/fa9cde52-5594-414b-b686-eee474cc0d51_20250624T17:25_UTC.wav
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[AGENT][POSITIVE] Thank you for contacting APR. My name is [PII]. How may I help you?
[AGENT][POSITIVE] Good afternoon. Thank you for contacting API. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling for the provider to check on additional information on a claim that has been denied. Please note, this call will be monitored and recorded for quality and training purposes.
[AGENT][NEUTRAL] OK, yes, I can certainly help with the claim. And [PII], what is that, uh, what is that policy number that we're looking at today?
[CUSTOMER][NEUTRAL] Policy number is 025.
[CUSTOMER][NEUTRAL] 854
[CUSTOMER][NEUTRAL] 56.
[AGENT][NEUTRAL] Thank you. And the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] [PII], with the date of birth [PII].
[AGENT][NEUTRAL] Thank you. Is there a callback number I can have in the event that we're disconnected?
[CUSTOMER][NEUTRAL] Yes, that would be [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]. It's a direct line.
[AGENT][POSITIVE] I do appreciate that. Thank you. And what date of service are we looking for for this individual?
[CUSTOMER][NEUTRAL] Yes, and for the data service is
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] And the total charges would be, mhm.
[CUSTOMER][NEUTRAL] $275.50.
[AGENT][NEUTRAL] $275.50. OK, let me just check here.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] I see. So this looks like it was for um occupational therapy. Does that sound right? The CPT code is 97,110 with a a modifier GO.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And 971-40 with a modifier G as in go and O as in Oscar. OK, yes, and how may I help, [PII]?
[CUSTOMER][NEUTRAL] Yes, it's with the additional information on the denial, please.
[AGENT][NEUTRAL] Yes, of course, um, the policy.
[AGENT][NEUTRAL] We'll pick up the deductible, co-payment or co-insurance.
[AGENT][NEUTRAL] For physical therapy.
[AGENT][NEUTRAL] But when we looked at this claim, and let me see, I can actually pull up the claim itself so we can just talk about it. Um, I'm just pulling up the documents this moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] it.
[AGENT][NEUTRAL] See what we have here.
[AGENT][NEUTRAL] And I apologize my computer is just a little bit slow, so I'll just get it here.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And the primary process it towards the copay.
[AGENT][NEUTRAL] So what
[AGENT][NEUTRAL] Right, yes, of course. I do see that. I, I do see the um um explanation of benefits, uh, from, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, Aetna, so let's look at the claim itself, which is which is where we're having our problems.
[AGENT][NEUTRAL] The modifier GO means occupational therapy.
[AGENT][NEUTRAL] Um, and, uh, so we can't, uh, the, the policy itself doesn't cover occupational therapy, speech therapy, or kinesiology therapy, and that's kinesiology therapy is like exercise therapy. But what we have here is occupational therapy, and that's what the GO in the in modifier.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And because it has that.
[AGENT][NEUTRAL] We are unable to to pay the claim. Now if the claim did not have that modifier we could look at it again, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Without that, uh, but because it has that GO modifier, we're not able to, uh, to process.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And just for confirmation, occupational therapy is not covered under this patient's plan, is that right?
[AGENT][POSITIVE] That is exactly right.
[CUSTOMER][NEUTRAL] Thank you. And is this patient's policy meddling?
[AGENT][NEUTRAL] This is the meddling policy, yes.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] And the outstanding amount, this is the patient's responsibility.
[AGENT][NEUTRAL] Well, we can't tell you that, [PII]. The only thing I can tell you is that uh we won't cover it. It's not uh covered under our contract. Um, I would, I would ask them if they don't have another policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] I would certainly get in touch with them and ask they have.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] And a car reference number, please?
[AGENT][NEUTRAL] My name is [PII], and the first letter of my last name is [PII], and what we're gonna do is we're gonna use that today's date as our reference.
[AGENT][NEUTRAL] Uh, is there any other claims for [PII] that we need to look at, or?
[CUSTOMER][NEUTRAL] Nothing else, that's it.
[AGENT][NEUTRAL] OK, well thank you for contacting ATO.