AccountId: 011433970860
ContactId: 0099f247-626e-49e5-9282-2bf7afc51c44
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1167479 ms
Total Talk Time (AGENT): 259175 ms
Total Talk Time (CUSTOMER): 409215 ms
Interruptions: 5
Overall Sentiment: AGENT=0.7, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/0099f247-626e-49e5-9282-2bf7afc51c44_20250408T15:42_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APO. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. How are you? This is [PII].
[AGENT][NEUTRAL] So he so how are you?
[CUSTOMER][NEUTRAL] I'm good, I'm good, thank you. Um, I have a member on the line with the cancer policy, and she's calling me about her claim that she said that she's been going, um, on with this for about a week, um, that she's been getting, you know, be saying that she needs additional information, but she believes she sent the last information which is the explanation of benefits that were asked for, um, but, um.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] So what's the policy number? maybe pull it up while you're talking.
[CUSTOMER][NEUTRAL] And she was pointing out.
[CUSTOMER][NEUTRAL] OK. 769-779.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] And let me know when you have it pulled up so I can.
[CUSTOMER][NEUTRAL] Probably tell you what she's telling me and maybe just let her know what's going on.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And it's the most recent claim.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And what she said is towards the bottom of the, you know, the paperwork she sent the 16 pages she sent, she's talking about the ones listed on page 1415, and 16 under the co-insurance, the co-payment.
[CUSTOMER][NEUTRAL] I'm not sure if that's exactly what we're looking for, but that's what she's pointing out, so I'm not sure if you just need something else.
[CUSTOMER][NEUTRAL] Or, how can we help her?
[AGENT][NEUTRAL] more detail
[AGENT][NEUTRAL] For the surgery
[CUSTOMER][NEGATIVE] She's a little bit frustrated because she don't know what else to say.
[AGENT][NEUTRAL] No
[AGENT][NEUTRAL] You can send her over. I'm gonna have to get with the examiner to see cause I don't see any of this information on this page that she got going on, so you can send her on over.
[CUSTOMER][NEUTRAL] Yeah, right.
[CUSTOMER][NEUTRAL] OK, here she can I fully verify her the call back number is the same on the system, OK.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Thank you for holding and being patient for Ms. [PII]. I got Miss [PII] on the line. She's in the claim support team, OK? OK.
[CUSTOMER][POSITIVE] Have a good day.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How are you?
[CUSTOMER][POSITIVE] Good morning.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] OK, good. Give me one second, I'm reviewing your claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, Ms. [PII], I, I'm looking at your claim, but I need to ask a question about um
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] What this examiner was trying to request from you, just to be sure, do you mind if I put you on a brief hold one more time?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, one second.
[CUSTOMER][NEUTRAL] Excuse me, you ask me a question?
[AGENT][NEUTRAL] I'm sorry. OK.
[CUSTOMER][NEUTRAL] OK, I'm sorry, never mind. You said you were gonna hold, right?
[AGENT][NEUTRAL] Yes, ma'am. Yes, ma'am.
[CUSTOMER][NEUTRAL] You put me on hold, right? Look at something. OK, that's right. I, it wasn't sure whether you asked me a question or not. That's alright. That's fine.
[AGENT][NEUTRAL] OK. No, ma'am. That's OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hey [PII], how's it going?
[AGENT][POSITIVE] I'm doing good. Look, I have a question. Can you look at something with me?
[AGENT][NEUTRAL] Alright. 769-779.
[AGENT][NEUTRAL] That's correct. And it's the last claim that you process requesting a more detailed EOB.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] OK great
[AGENT][NEUTRAL] 8
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And so I, I was trying to figure out what, when you, when you need the more detail that you will be, what are, what are you all looking for on cancer?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. So, basically, uh, I just don't know that we can't use the medical claim detail. We have to have the actual EOB. OK. All right. All right. That's what I want to know.
[AGENT][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] Bye-bye.
[AGENT][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, thank you for holding. I do apologize for the wait.
[CUSTOMER][NEUTRAL] That's fine.
[AGENT][NEUTRAL] OK. So, uh, what she explained to me was the information that, that was received was the medical claim detail.
[AGENT][NEUTRAL] So it's not the actual explanation of benefits, so we need the actual explanation of benefits from Blue Cross and Blue Shield. They can't use the medical claim detail.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, well that's what they send me, you know, that's the medical claim details what they send me, um, in the mail. I don't get, you know, so I have to request that from the company. If you look on the cover letter that's Yeah, but on the cover letter for those pages it says that's an explanation of benefits.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That comes with that that explanation of benefits.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It says an explanation. I mean that's, that is what comes. I didn't send the cover page for it. Do I need to send the cover page?
[AGENT][NEUTRAL] Uh-huh, let's see, cause usually the explanation of benefits we get from Blue Cross looks a little bit different. There, there are some explanation of benefits that are specific to like certain dates of service, and I'm, I'm thinking that's what they're looking for, uh.
[CUSTOMER][NEUTRAL] That's what it says.
[AGENT][NEUTRAL] So like for the 101.
[CUSTOMER][NEUTRAL] I made it.
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] Go ahead. No, go ahead. You go ahead. What can I say because I've got it. I mean, for that 10-11, it's got it listed out over 3 pages, you know, 3 things, 3 pages of things, one for the hospital visit and then, you know, the surgery and then the uh the lab services so it's broken out like that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, cause let's say specifically for the surgery, that's $2,165.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] I'm not seeing that amount listed here on the claim detail that was sent in.
[CUSTOMER][NEUTRAL] This for the 101, just for the 101 you're looking at? OK, let me look at that.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] No, I mean the 1011, the 1011, I'm sorry.
[CUSTOMER][NEUTRAL] 1011 by 10:11.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, OK, for 1011.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] 21 let's see 1011.
[CUSTOMER][NEUTRAL] OK, for 1011 I have surgery and then there's a $280 charge there.
[CUSTOMER][NEUTRAL] And then on a different page and then there's an ultrasound that's 101 it's for that same day and then on another page there's a bunch of lab like about 6 different lab services and then on the third page they have the hospital visits or facility visit which the amount charged was 470,460.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The the the the plan paid 3,34705, uh, the deductible was zero because we'd already paid that and then it says copay coinsurance 37189.
[AGENT][NEUTRAL] OK. And because the charge that they're looking at is uh $2,165.
[CUSTOMER][NEUTRAL] Is that something that came off the itemized?
[CUSTOMER][NEUTRAL] Report then?
[AGENT][NEUTRAL] Uh, I'm not showing
[CUSTOMER][NEUTRAL] I see right here that you say did you say 2,165?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes, ma'am. And so that looks like those were the
[CUSTOMER][NEUTRAL] OK, so that.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Yeah, that was listed for the needle biopsy on the itemized report.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and that.
[CUSTOMER][NEUTRAL] But they did not specifically on the on the explanation of benefits and that's what you're looking for.
[AGENT][POSITIVE] Yeah, so that's what we're needing that's what we're looking for, yes ma'am.
[CUSTOMER][NEUTRAL] OK, and then the same thing on the PET scan?
[AGENT][POSITIVE] Yes ma'am, that's correct.
[CUSTOMER][NEUTRAL] OK, let me see.
[CUSTOMER][NEUTRAL] So what are they looking for on the PET scan on that itemized report?
[AGENT][NEUTRAL] Um, that one, the charges for that, for that, uh, scan was $5,326.
[AGENT][NEUTRAL] And so I don't see that that's listed here either for 101.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, $5,326. So let's see that's listed here. So apparently they have broken it out differently on the explanation of benefits, I guess. I see, and then I have a procedure on my, uh, the thing that you sent me one more information it says uh please submit please submit ELB that matches claim for 385505 procedure code. So what is, what is that? Is that the
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I mean I don't know what that procedure code stands for.
[AGENT][NEUTRAL] Uh, let me look that up for you. Give me one second.
[CUSTOMER][NEUTRAL] Mm. So is that what I asked the insurance company? Is that what I asked the insurance company for?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So that was the needle biopsy. So that's probably gonna be the, the doctors. Was there a surgeon that performed the needle biopsy?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so, so his, so his charges are probably gonna be separate from the hospital, so we would need uh the EOB that matches uh the charges that he did and so that's probably gonna be that $2,165 charge.
[CUSTOMER][NEUTRAL] Yeah, well.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, then the same thing for the PET, the PET scan, they're wanting matching the claim for procedures 78816.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that's the scan. Yes, ma'am.
[CUSTOMER][NEUTRAL] As that procedure code.
[CUSTOMER][NEUTRAL] That's the thing.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, so I, I mean, I see those amounts on the itemized list.
[CUSTOMER][NEUTRAL] Um, but they just, they aren't broken out like that on what I got from my explanation of benefits.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I guess I called the the Blue Cross company.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEGATIVE] See now I'm, I'm concerned going forward because then I had.
[CUSTOMER][NEUTRAL] I, I had 6 chemotherapy treatments after that. I'm gonna have to do the same thing for those.
[AGENT][NEUTRAL] Yes, because, uh, I wanna say she have, we have to have something with the actual charges.
[CUSTOMER][POSITIVE] It's actually got something in the mail.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] I mean, I don't, I mean, I thought that's what the itemized, uh, bill of charges was for.
[AGENT][NEUTRAL] But they have to see the actual.
[CUSTOMER][NEUTRAL] I mean, I'll put that.
[AGENT][NEUTRAL] The actual bill charges and usually the explanation of benefits are gonna have the actual bill charges so that's why they have to have the um explanation of benefits that matches those charges.
[CUSTOMER][NEUTRAL] So it looks like to me they're lumping something together somewhere.
[CUSTOMER][NEUTRAL] Because I'm not seeing those, those things that those are, you know, those exact amounts I found them on out of my field, but I'm not seeing on the explanation of benefits. OK, alright, well I guess I'll call Blue Cross, you know, this is, I, I've had this policy for years.
[AGENT][NEUTRAL] Yeah, I
[AGENT][NEUTRAL] Yeah, cause actually the doctor.
[AGENT][NEUTRAL] Yeah, but the doctor actually submitted the charges previously.
[CUSTOMER][NEUTRAL] I mean when I called and they told me that is why I did exactly what they told me so this is a run around, yeah, because I actually have had this policy and used it 6 years ago because I had another cancer 6 years ago and I did not have all this. I had to deal with unless y'all change things.
[AGENT][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Oh OK.
[CUSTOMER][NEUTRAL] So, uh, you know, because basically they told me you need to file this yourself. You don't need to go through an office, so that's why I've got a duplicate thing now because I wouldn't went back and send everything back in and they told me just send the, you know, ELB that you have and whatever. OK, well I'll see if I can find that, find that information. Alright, thank you.
[AGENT][POSITIVE] OK. You're welcome. Have a great rest of your day.
[CUSTOMER][NEUTRAL] Bye.