AccountId: 011433970860
ContactId: 0a887e75-c6d8-4bbf-8562-35ef9883d8db
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1103579 ms
Total Talk Time (AGENT): 521741 ms
Total Talk Time (CUSTOMER): 260920 ms
Interruptions: 4
Overall Sentiment: AGENT=0.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/04/0a887e75-c6d8-4bbf-8562-35ef9883d8db_20250404T14:10_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Good morning [PII]. I have 2 claim numbers and I wanna see if I can find out some information on them because it says it's been completed and I wanna know what is going on with the situation on that.
[AGENT][NEUTRAL] OK. Are you the insured or are you calling on behalf of a provider?
[CUSTOMER][NEUTRAL] I'm the insurer.
[AGENT][NEUTRAL] OK, and you're wanting to check claim status on 2 claims that you've received notification about?
[CUSTOMER][POSITIVE] Yes, because it says it's been yes, because I got a text message right now that it's been completed.
[AGENT][NEUTRAL] Is that correct?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, yes, ma'am. I can help you with that. And who am I speaking with?
[CUSTOMER][NEUTRAL] [PII] and do you want me to give you the claim numbers?
[AGENT][NEUTRAL] Uh, no, ma'am, not yet. I'm sorry, what was your last name?
[CUSTOMER][NEUTRAL] [PII] [PII]
[AGENT][POSITIVE] OK, thank you. And Miss [PII], what is the
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] The callback number for you please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Yes ma'am, what is a good call back number for you?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And your policy number, please?
[CUSTOMER][NEUTRAL] My policy number? I don't have it with me.
[AGENT][NEUTRAL] OK. Are you the subscriber on this, Ms. [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and what is your social so that I can look up your information, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] I'm sorry, [PII]. And what was the, what was the rest of it?
[CUSTOMER][NEUTRAL] [PII], can you hear me?
[AGENT][NEUTRAL] Uh, yes, ma'am, I can now, but there's just some background noise that's making it a little difficult, so just one moment.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, Miss [PII], I will need to verify with you for security and also any information that's provided today will be a
[AGENT][NEUTRAL] Verification of benefits and not a guarantee of payment. First off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and your home mailing address?
[CUSTOMER][NEUTRAL] It's uh [PII].
[AGENT][NEUTRAL] Thank you. The phone number that is on file for you is the same as the one you gave me, so that is your best contact number, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. And lastly your email address and this may be your work email.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you very much.
[AGENT][NEUTRAL] OK, so for I do see that there were two claims that were processed on yesterday, um, the first claim number ends in 83.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that claim has been denied. This was for [PII], is that correct?
[CUSTOMER][NEUTRAL] I don't know. I don't know, I have him in front of me, so I don't know.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, OK. All right. So, uh, according to the denial remark, it states.
[CUSTOMER][NEUTRAL] It just says it's been completed, that's all I know.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so the first one, claim number 3584483. Yes, ma'am, that claim was denied. The reason for the denial states the calendar year maximum for the medical imaging benefit has been met.
[AGENT][NEUTRAL] And that is also the same remark for the claim number 3584498.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] OK, so then nothing's gonna get paid on this end.
[AGENT][POSITIVE] Yes, ma'am, that is correct.
[AGENT][NEUTRAL] Due to the calendar year maximum for medical imaging benefit has been met.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Wow, how many imaging do I get per year?
[AGENT][NEUTRAL] Let me pull your policy information up. One moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] It's still loading this information for me, so please bear with me.
[AGENT][NEUTRAL] OK, so for medical imaging tech, it's the benefit max per calendar year.
[AGENT][NEUTRAL] It's per test up to a maximum of ones.
[AGENT][NEUTRAL] Per cover person per calendar year following the diagnosis of cancer, and that benefit is $500 but it's one test per calendar year.
[CUSTOMER][NEUTRAL] So that one has already been paid for.
[AGENT][POSITIVE] I'm so sorry. Could you please say that again?
[CUSTOMER][NEUTRAL] So that one has already been paid for through the year.
[AGENT][POSITIVE] Yes, ma'am, that is correct.
[CUSTOMER][NEUTRAL] That I had it, OK.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] What was the other thing?
[AGENT][NEUTRAL] Mm, that was all that I said. It was 10 medical imaging.
[AGENT][NEUTRAL] Was one test per cover person per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] I don't remember, but I guess.
[CUSTOMER][POSITIVE] Alright ma'am thank you I just wanted some information.
[AGENT][NEUTRAL] Oh yes, ma'am, I totally understand. And you will be able to access that explanation of benefits in your portal too, Ms. [PII], probably, um, either if not late this afternoon, it should be there by, well, today's Friday. I was about to say tomorrow, but that wouldn't be the case, uh, Monday, probably.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] If not later this afternoon.
[CUSTOMER][POSITIVE] OK. All right. OK, ma'am, thank you so much. Uh huh bye bye.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All right. Well, you're very welcome. Is there anything else I can help you with this morning?
[CUSTOMER][NEUTRAL] No, ma'am. I just wanted some information because I know I didn't get um.
[CUSTOMER][NEUTRAL] Um, APL was for my cancer, right? Because I don't think I have this claim anymore, I mean policy anymore, and um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But
[AGENT][POSITIVE] Right, that is correct.
[CUSTOMER][NEUTRAL] I know I went through chemo and treatments and stuff. Did they pay that out? Does it show anything like that?
[CUSTOMER][NEUTRAL] My treatments?
[AGENT][NEUTRAL] I do show a claim was processed back in April.
[AGENT][NEUTRAL] And these were for all dates of service in [PII]. And yes, ma'am, it was um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me look at some of these remarks. Give me just one moment, please.
[CUSTOMER][POSITIVE] Yes, I do.
[CUSTOMER][NEUTRAL] I have um, [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. From what I can see, this was
[AGENT][NEUTRAL] We, it was a pre it was more for your drugs that the benefit was paid. Let me look at this.
[CUSTOMER][NEUTRAL] And drugs.
[AGENT][NEUTRAL] Right, related to your chemotherapy.
[AGENT][NEUTRAL] Now, I do not see an actual claim for your treatment itself. On the claim that was previously reviewed, it's, there was a denial stating the radiation therapy, chemotherapy, or immunotherapy benefit does not cover other procedures related to radiation, chemotherapy, or immunotherapy treatment.
[CUSTOMER][NEUTRAL] So the chemotherapy wasn't covered.
[AGENT][NEUTRAL] Such as treatment planning, treatment management.
[AGENT][NEGATIVE] It does not show that. It doesn't show that we received for the actual chemotherapy itself. It was for something related.
[CUSTOMER][NEUTRAL] No, because it was all chemotherapy.
[AGENT][NEUTRAL] Again, the remark on here, let me finish.
[CUSTOMER][NEUTRAL] No radiation.
[CUSTOMER][NEUTRAL] Yeah, I didn't get any radiation.
[AGENT][NEUTRAL] Right, but that's all one benefit. It's how the language is worded in your policy, so that's going to be just how it's worded.
[AGENT][NEUTRAL] Because the maximum benefit is for all, you know, for radiation, chemotherapy, and immunotherapy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What is all one benefit on this policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I just wanna know if it's been paid for. If not, I have to submit a claim or what?
[AGENT][NEUTRAL] Yes, ma'am. It does not show that that has.
[CUSTOMER][NEUTRAL] Or is it not covering?
[CUSTOMER][NEGATIVE] It's just what? I don't understand you.
[AGENT][NEGATIVE] It doesn't show that we received.
[AGENT][NEUTRAL] OK, let me read you the remark.
[CUSTOMER][NEUTRAL] So do I have to uh-huh.
[AGENT][NEUTRAL] It appears that based on what I can see for the treatment, the, for the
[AGENT][NEUTRAL] chemo that we, information we received, it wasn't for the cells. It shows that it was for the remark on the denial states that it does not cover procedures related to radiation, chemotherapy, or immunotherapy treatment, such as treatment planning, treatment management, or consultation.
[AGENT][NEUTRAL] Design and construction of treatment devices, radiation to symmetry, calculation, lab tests, X-ray scans, medical supplies and equipment used in the administration.
[AGENT][NEUTRAL] Such as IV solutions, needles, dressings, pumps, catheters, etc. I'm not seeing a claim for the actual chemotherapy itself, according to the most recent claim that was reviewed.
[CUSTOMER][NEUTRAL] Yeah, cause what I had was chemotherapy and I had that from August all the way to November.
[AGENT][NEUTRAL] OK. So, yes, ma'am. I'm not seeing a claim.
[AGENT][NEUTRAL] The actual therapy itself.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But you can still submit those claims.
[CUSTOMER][NEUTRAL] So,
[AGENT][NEUTRAL] So the
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, ma'am. Go ahead. Mhm.
[AGENT][NEUTRAL] Now
[CUSTOMER][NEUTRAL] So then I'm gonna go ahead and.
[CUSTOMER][NEUTRAL] Does it show anything cause I, what happened with me is that I was at MD Anderson in August and I was hospitalized for a week.
[CUSTOMER][NEUTRAL] And then I was released in [PII].
[CUSTOMER][NEUTRAL] After a week and then I was hospitalized at Valley Baptist.
[CUSTOMER][NEUTRAL] Because my platelets level went down.
[CUSTOMER][NEUTRAL] And then I started my chemo treatments.
[CUSTOMER][NEUTRAL] At the end of the month.
[AGENT][NEUTRAL] OK, so I
[CUSTOMER][NEUTRAL] Locally closer to home.
[AGENT][NEUTRAL] Mhm. Now, was this in [PII]?
[AGENT][NEUTRAL] Or [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. Let me look because if you, when you're signed into your portal, you're gonna see that you have two policies with APO. Let me look at your other policy that was active from [PII] [PII]. So give me just a moment to see if there was anything processed under that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No
[AGENT][NEUTRAL] I see surgery that was processed back in [PII].
[AGENT][NEUTRAL] There were several dates of services, but I'm not seeing anything for later in the year.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Oh thank you.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] So then you don't show anything.
[AGENT][NEUTRAL] Of that year.
[CUSTOMER][NEUTRAL] What did you say again? I'm sorry, you cut off.
[AGENT][NEUTRAL] I'm not seeing any claims for later in the year for you.
[AGENT][NEUTRAL] For your treatment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But you are showing.
[CUSTOMER][NEUTRAL] The surgery and everything, right?
[AGENT][NEUTRAL] What was the date for that?
[CUSTOMER][NEUTRAL] For the surgery?
[CUSTOMER][NEUTRAL] The surgery was done in June.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] [PII], I think.
[AGENT][NEUTRAL] Do you know what day?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII] uh.
[AGENT][NEUTRAL] I don't see surgery charges for June um in.
[AGENT][NEUTRAL] And all I see is a lodging charge. That was for the [PII].
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Yeah, cause I had a bladder, partial bladder removal.
[CUSTOMER][NEUTRAL] It doesn't show anything with that?
[AGENT][NEUTRAL] I, no, ma'am, I don't see anything for actual surgery.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Do they cover that?
[AGENT][NEGATIVE] Not for those
[CUSTOMER][NEUTRAL] Huh?
[AGENT][NEUTRAL] Let's
[CUSTOMER][NEUTRAL] The what, ma'am?
[AGENT][NEUTRAL] Yes, ma'am, you would have a surgical benefit. So you can still submit the claims for the treatments and for your surgery that we haven't received. You can actually print your claim form, as from our main website, and the first page of that claim form you can use as a checklist for the documents that you would need to provide to us.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the website that you would go to to get your claim form if you don't already have that would be [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] At a
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, I'll go ahead and look for it and I'll try to figure this out myself.
[CUSTOMER][NEUTRAL] And I'll submit the, the chemotherapy paperwork.
[AGENT][NEUTRAL] Well, is there anything else?
[CUSTOMER][POSITIVE] No, ma'am, thank you so much and then I guess I have two policies, right?
[AGENT][NEUTRAL] OK. Is there anything else that I can help you?
[CUSTOMER][POSITIVE] No ma'am thank you uh huh.
[AGENT][NEUTRAL] Yes, ma'am, and when you're signed into your, when you're signed into your portal, you will be able to see that you have one policy from [PII].
[AGENT][NEUTRAL] So if you had any services within that date range, you would use that policy number, and the other policy number shows 9-1-2023 to when your policy ended, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 24 OK.
[AGENT][NEUTRAL] Mhm. And but you'll be able to see that online, signed in.
[AGENT][NEUTRAL] And the 2 different policy numbers also.
[CUSTOMER][NEUTRAL] Yes, ma'am. OK.
[CUSTOMER][POSITIVE] All right, thank you so much. Uh-huh.
[AGENT][NEUTRAL] Oh
[AGENT][POSITIVE] You're certainly very welcome. And if that is all then that I can help you for calling APL and I hope that you have a very nice weekend, Miss [PII].
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you. Bye-bye.