AccountId: 011433970860
ContactId: 0bb72b48-b5ce-4471-ba3c-9d76a0ac7d48
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 754090 ms
Total Talk Time (AGENT): 391420 ms
Total Talk Time (CUSTOMER): 419444 ms
Interruptions: 16
Overall Sentiment: AGENT=0.2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/27/0bb72b48-b5ce-4471-ba3c-9d76a0ac7d48_20250227T14:58_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. With whom am I speaking and how may I help you?
[CUSTOMER][NEUTRAL] My name is [PII], and I'm calling about trying to understand something on a claim that I sent in and um seeing on my schedule, it says that a doctor's visit is not
[CUSTOMER][NEUTRAL] Covered under my plan, but I, I have all of my stuff done at the cancer center and I have to have, I have 33 appointments every time I go there I get blood work and I get, see the doctor and then I go into, you know, the infusion room and have my, you know, where they do the chemotherapy and they have my infusion, but it said that none of that was covered on the last claim that I turned in and I'm trying to understand and it says on my um
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] The schedule of benefits, it says that the lab work is supposed to be covered every time and the uh my immunotherapy is supposed to be covered, but it's not being paid and I was just trying to find out and get an understanding of why that's happening.
[AGENT][POSITIVE] OK, so I'll be more than happy to go over your benefits with you and what that schedule of benefit page means is what's going to be covered. What is a good call back number for you in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Area code [PII].
[AGENT][NEUTRAL] And what's your policy number?
[CUSTOMER][NEUTRAL] Uh, it's 00727573.
[AGENT][NEUTRAL] Thank you for that information, Ms. [PII]. Please allow me one moment while I get that policy pulled up and, and then I'll be able to have, I'm gonna have you verify uh your date of birth first, followed by your mailing address, please.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] What's your date of birth?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And what is your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that information and one moment, my system is moving slow. OK, and what is the last piece of verification would be the email address that we have for you, but my system is moving really slow. Mhm, go ahead.
[CUSTOMER][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] OK, [PII].
[AGENT][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you for verifying all that information for me, Miss [PII]. OK, one moment please. Let's take a look.
[AGENT][NEUTRAL] Let me pull your policy certificate and then I can help you uh better understand uh the benefits of your policy, OK? No problem.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] And I just ask that you be patient because this system is moving really, really slow.
[CUSTOMER][NEUTRAL] It's not a problem, sweetheart. Not a problem. I'm not doing anything. Just, just trying to find this information.
[AGENT][NEUTRAL] OK. All right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you for your patience.
[AGENT][NEUTRAL] All right. So, we're gonna start with office visits, OK? So, absolutely none of our cancer products that we sell cover office visit, OK?
[AGENT][NEUTRAL] An office visit is just what it is. It they just bill in an office visit, but when you go in for immunotherapy, they may bill you as coming in for an office visit, but that office visit is not covered under this policy, but the immunotherapy is. So we would pay your immunotherapy, but we're not gonna pay an office visit. Now, in term.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well, see, I understand that. Yeah, but they said the last thing I sent in, they, they put it in there as an office visit, but I have the, uh, you know, the, I had the infusion, you know, in there. I have to every time I go see the doctor but I have to go to the other part of the hos you know, the cancer center to get my infusion. I have to sign in and it's another whole appointment.
[CUSTOMER][NEGATIVE] And that's what I'm trying to understand is why they still not paying it.
[AGENT][NEUTRAL] So that would have been the claim that you recently was paid on [PII], is that the one you're referring to?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am, I think so, yes ma'am. They, they paid $60 for an office.
[AGENT][NEUTRAL] OK, let me, let me.
[AGENT][NEUTRAL] Yeah, they, no they pay $60 for your preventative.
[AGENT][NEUTRAL] It was a test that you had done that could that fell up on the preventative we could pay that up on the preventative. That's why you were paid $60.
[CUSTOMER][NEUTRAL] What what
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] I don't even know what I didn't have a test done that unless you know unless they did it with the blood work and didn't. Yes, ma'am.
[AGENT][NEUTRAL] OK, so let's
[AGENT][NEUTRAL] It was the blood work. It was a blood work and it's a test that, a blood work test that can be considered as a preventative cancer test. So we paid that. Uh-huh. And that's what that is. That's a CA 15-3. That's for a cancer um blood test, OK? So that's why we pay you that $60. But let me take a look and see what all was billed on this office visit. Let's see here.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am. Yes ma'am.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEGATIVE] I never had a problem with it before. Now this this last year, I, I really had a problem with it because they denied my first claim I sent in in September and I they said that they had already paid everything for the year and my year didn't start until [PII]. So I had a, you know, with cancer, you don't, you don't have no.
[CUSTOMER][NEGATIVE] You don't got no time to wait on nothing really, you know what I'm saying? I have stage 4 metastatic breast cancer and um every time I send something in it it's either nothing paid or it's uh
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] You know, it's just something and, and I've not had a problem before. I've had this policy a good long time and I've been blessed to hang in there with all the different, you know, medications and stuff that I've been able to get, you know, have. So I just, like I said, I'm not trying to get anything that I'm not supposed to have or anything like that, but I just was just wondering how they didn't pay for the, the infusion that I had and they said that they, the lady told me they pay for the medicine.
[AGENT][NEUTRAL] OK, so what
[AGENT][NEUTRAL] So, so as I stated to you, Ms. [PII], I'm pulling the claim. I'm gonna look and see if you submitted something for infusion because I don't see a reason why we would not pay your infusion if there was a benefit available now in looking at the claim where you were paid $60 you submitted that documentation. Let me see what date this claim was submitted. You submitted this for review on we received it on [PII] and you submitted.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEGATIVE] It's 7 pages in all, OK? The first page is just a title page with your name on it and your identifying information, your date of birth. The second page was blank. The 3rd page is from Franciscian Missionaries of Our Ladies' Health System, and it says on [PII] you had an office visit. That's not covered, OK, so that's not infusion.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Infusion is a different code. When you get infusion, that's a J code. We'll, we'll know.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well, that's the problem. Yes, ma'am, that's the problem. I think that they put the wrong code in there because I had the infusion. I had the Zamata and I have, you know, I have to.
[AGENT][NEUTRAL] OK, so let me explain that to you. Let me, you ain't let me get that far now.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright, I'm sorry baby. I'm sorry for that.
[AGENT][NEGATIVE] And so that's OK. That's all right. So, page 4 was blank. Page 5 is the zouronic acid. That's what you were infused with. But that is not covered under any of our cancer plans. So, I'm gonna look in your history and I'm gonna see if we ever paid you for that because that's something that's never been.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Well, you know, that that that's cheaper is what I was getting and the insurance wouldn't pay for the TV anymore and I think that's what that I had that one before, but I, I never really looked at when I get the paper, like I said, my daughter takes care of it for me because I don't know anything about the computer and stuff and so do you know what they, why did they send a blank page? That's what I'm trying to find out now. I, I think those people.
[AGENT][NEUTRAL] Yeah, it's not
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Oh, I just think, I just think, I just think when it's, did you upload this to your online service center account? You, OK, that's why. It just does that. That's just the online service center. It does that. It puts the page in between and it, it doesn't mean, but you did receive an infusion, but unfortunately, the Zolonic acid is not covered. That's not covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, ma'am. Yes ma'am. My daughter did.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's not the medicine that, oh, I see, I see, sweetheart, I see. Well, do they have something that tells what medications are covered or not or just, uh, just, um, um, that, that cause like I said, that the reason I was concerned about it because I always, when I was getting ext they always paid for it and I didn't, and I didn't know that this one wasn't.
[AGENT][NEUTRAL] Yes, ma'am. That's why, and I, I see that.
[AGENT][NEUTRAL] Yes, and that one is a covered one.
[AGENT][NEUTRAL] Mhm. That one is a covered one. And unfortunately, unfortunately, we don't publish a list of the drugs that are covered, but if the doctor switches it to something else, um, you're more than welcome if they give you the name of a different drug.
[CUSTOMER][NEUTRAL] Yeah, I see, I see, I, I understand.
[CUSTOMER][NEUTRAL] Acting
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Well, see, that's what, that the other medication that I'm having, even my medication I take by mouth. I had been taking the um Trucrop and I broke out, it broke out and they gave me another medication called Udo and I sent that in, but I don't know if they'll, if that's in the list of things to be done.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Oh, they, 00, they, they are, let me take a look at that. I think that's being reviewed, so that's currently being reviewed. So don't, don't, you know, just, uh, yes, ma'am. That's, that's under review to see if that one gonna be covered.
[CUSTOMER][NEUTRAL] Yes, ma'am. Yes ma'am.
[CUSTOMER][POSITIVE] Well, I appreciate your time for that.
[CUSTOMER][POSITIVE] But I understand now and I won't, I won't be bothering y'all no more because I really didn't know what the problem was and I was thinking that, you know, you said that immuno the but it's certain ones that you have in your list that uh you can pay for. I understand so much and I thank you for your time, sweetheart.
[AGENT][NEGATIVE] No, no, no, no, no, no. Listen.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] And it's, it's not
[AGENT][NEUTRAL] You're welcome, but let me explain your blood to you too. So, you do have a blood plasma and platelets benefit. That's what you're looking at on your schedule. And what that means is if you have to have a blood transfusion. So, no other blood work other than
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Oh well, no, I haven't so far I hadn't had time.
[AGENT][NEUTRAL] Yes, ma'am. Other than the procedure codes that would be considered a blood transfusion, OK?
[CUSTOMER][NEUTRAL] OK, so this that says administrative lab work benefit does not count.
[AGENT][NEUTRAL] That counts only for, again, that, that wouldn't cover any other labs. That's just gonna pick up like if you had chemo and chemo usually has an administration procedure code.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] And then sometimes it will have certain lab codes that go along with it, that will only be covered if you receive chemo, radiation, or immunotherapy. And they build, they have to build those specific codes, but it's not just plain lab work. Yeah, not a, not a, yes, ma'am, not your regular lab workup.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Oh yeah. Well, see, that's the thing.
[CUSTOMER][NEUTRAL] I see, I see.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Oh, I see, I see, see, I, I didn't know that because they always when I was getting the two injections, I was getting um um I was getting uh yes ma'am, I was getting 2 injections. uh I had usually got 3 when I was taking this other medication, but it, they stopped it and they just gave me the thing for my bones and that's the one that's not, that's not being paid for. That's the one that, that y'all don't have in your list.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] That administrative lab fee mhm.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] Yes ma'am, that's right.
[CUSTOMER][POSITIVE] That's later. Yes, ma'am. Yes ma'am. Well, thank you, sweetheart. I appreciate your time and I understand now, and it's good to just have somebody explain it to you because I wouldn't have known this because I was just uh here in a nervous dinner because I'm, I got the policy out. I said I, I know it's supposed to do something, but now I understand everything that you've told me and I really appreciate it.
[AGENT][NEUTRAL] The zolarronic acid. You're welcome. Did you have
[AGENT][NEUTRAL] OK. Did you
[AGENT][POSITIVE] Yes, ma'am. Anything else I can help you with?
[CUSTOMER][POSITIVE] No, ma'am, that's all. I appreciate your time and everything and, and being able to explain it.
[AGENT][NEUTRAL] All right. And Miss, Miss [PII], you take care of yourself and if you have any other questions, call back. I'm [PII] and I'm in the cancer department, OK?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] Yes, ma'am. I, I appreciate it. Yes, ma'am. Thank you so much. You have a good day. All right.
[AGENT][POSITIVE] You're welcome. Take care. Thanks for calling APL. You as well. Bye-bye.
[CUSTOMER][NEUTRAL] Bye-bye.