AccountId: 011433970860
ContactId: 0ae0ca27-e100-46ac-b7e5-40021fe251aa
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 724419 ms
Total Talk Time (AGENT): 211044 ms
Total Talk Time (CUSTOMER): 128887 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=-1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/0ae0ca27-e100-46ac-b7e5-40021fe251aa_20250213T17:09_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh, yes, [PII], I'm calling in regards to a claim that I filed. Y'all called me yesterday but I didn't get the call, so I'm returning the call.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you and see who gave you a call and um see if I can connect you with them. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Uh, [PII], last name is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you for that. And [PII], may I have your policy number?
[CUSTOMER][NEUTRAL] Uh, policy number is 00707760.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And I have you here. I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] What was the other one?
[AGENT][NEUTRAL] Oh, your email address?
[CUSTOMER][NEGATIVE] Oh, [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alrighty, and thank you so much for verifying your information and all the information provided is a verification of benefits, not a guarantee of payments. And do you mind if I place you on just a brief hold? I'm just gonna, I'm trying to see who gave you a call and if I can get you back with them.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh wait.
[AGENT][NEUTRAL] But how long the policy been active?
[AGENT][NEGATIVE] What the heck is that?
[AGENT][NEUTRAL] DG.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] If you have and if you have additional information that shows that these treatments were being received at the same time as the anti-nausea.
[AGENT][NEUTRAL] Oh Lord. How was that? Oh Lord.
[AGENT][NEGATIVE] Hello Ms. [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So it looks like the representative um was giving you a call in reference to um
[AGENT][NEUTRAL] Your claim 353-9793?
[AGENT][NEUTRAL] Um, so were you, did you have questions about the denials or how can I assist you with the claim?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, um, this is a, um, cancer drug that I've been taking since [PII], and I didn't realize that my policy back then even paid for medication, so I never submitted any anything for medication, but now I understand that the, uh, the policy does pay medication.
[CUSTOMER][NEUTRAL] So I'm on a cancer drug that I take twice a day, and I'm wanting to know what I need to do to send to y'all like, do I need the doctor to write a note or how do I go about uh collecting for that? I don't want to collect for it, obviously, it's too late from [PII] on, but I would like to collect for it going forward.
[AGENT][NEGATIVE] OK, um, so yes, that was one of the denial reasons. One of the um dates of service on here was [PII], so that's why it was denied. It was denied because, well, that, that particular code was denied because it was.
[CUSTOMER][NEUTRAL] Well, I sent
[CUSTOMER][NEUTRAL] I sent in the biopsies, uh, they, they requested those, and I think I sent those in at the same time that I sent in the Walmart for the medication. I didn't mean to go back to [PII]. I just was wanting to start it at this point if I can and at least get paid for the uh medication if I can.
[AGENT][NEUTRAL] OK, so yes, that was one of the, um, I was just letting you know that's one of the reason the denial reasons on this claim was because it was [PII], but you already know about that. Um, so the next denial reason, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] This one I'm gonna ask for more clarity on. um oh, within the policy, OK. So,
[AGENT][NEUTRAL] The next one was for [PII], and it has on here, um, the policy does not cover a specified disease for which medical advice or consultation can be received within 12 months prior to the effective date of coverage. So because this policy became effective on [PII], the date of service is [PII], it wasn't a full 12 months.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. So how do I
[AGENT][NEUTRAL] Um, so that's the only reason that one.
[CUSTOMER][NEUTRAL] OK. How do I get it, is it possible to get my medication covered or no?
[AGENT][NEUTRAL] I can look at your benefits and let you know, but that's why the, I'm just letting you know why the claims were denied so far from the medication that you're trying to get, um.
[CUSTOMER][NEUTRAL] Right, right.
[AGENT][NEUTRAL] Hold on one moment. Let me just pull up your benefits.
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold? I'm just pulling up your policy documents.
[CUSTOMER][NEUTRAL] That's fine.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What do you wanna know?
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hm
[AGENT][NEUTRAL] We will pay the indemnity amount.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Once per month, once per month for anti.
[AGENT][NEUTRAL] Nausea and pain medication prescribed by a physician who[PII] also
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, hello, Ms. [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] All right, thank you so much for holding. So the policy would only um pay once per month for anti-nausea or pain medication that's um prescribed if it's if you're also receiving um radiation, chemo, or immunotherapy at the at the same time, um, or a surgery.
[CUSTOMER][NEUTRAL] OK, so it doesn't pay for the actual cancer drug?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] That was all I needed.
[AGENT][POSITIVE] Alrighty. Well, thank you so much for calling APL and I hope you have a good day.
[CUSTOMER][NEUTRAL] I see this time.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.