AccountId: 011433970860
ContactId: 0bcde0c7-680f-4740-b008-9d7295a21da5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 515597 ms
Total Talk Time (AGENT): 241481 ms
Total Talk Time (CUSTOMER): 283918 ms
Interruptions: 1
Overall Sentiment: AGENT=0.9, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/21/0bcde0c7-680f-4740-b008-9d7295a21da5_20250221T17:19_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] here. How can I help you?
[CUSTOMER][NEUTRAL] [PII], I'm trying to get some information about a claim that I filed and um I was trying to uh find out why uh I did, they didn't pay the lab work um uh what do you, I have my policy number, uh it's 0007.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 27573
[AGENT][NEUTRAL] OK, thank you and can I have your name?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][POSITIVE] Thank you and what's a good call back number in case we're disconnected?
[CUSTOMER][NEUTRAL] Area code [PII].
[AGENT][NEUTRAL] Alright, thank you and verify your address and date of birth.
[CUSTOMER][NEUTRAL] My address is [PII]. My date of birth is [PII].
[AGENT][NEUTRAL] Alright, thank you Miss [PII] and also verify your email address.
[CUSTOMER][NEUTRAL] My email address is [PII].
[AGENT][NEUTRAL] All right, thank you for verifying that information and you're calling about a claim um is the most recent claim?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am. It was on [PII]. Um, uh, my daughter does everything through the portal. So, uh, she was telling me that they didn't pay the lab work this time and in my policy, it says that it pays for the lab work. I've been kind of having problems because when I filed my claim back in uh September, they denied it and I had to wait until it was redone because they said that uh I had already
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Use up the money for the year, but they finally got it straight. So I'm just checking on this it may be something that's not gonna be paid, but I just want to see what I could find out.
[AGENT][NEUTRAL] OK, sure I can take a look at that. Alright, let's see.
[AGENT][NEUTRAL] OK, so I show the most recent claim processed on the I'm sorry, the [PII].
[AGENT][NEUTRAL] And that was for uh [PII] visit.
[CUSTOMER][NEUTRAL] Yes ma'am, somewhere like that. I, I thought it was the [PII] but it was the [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] No problem. Yeah, so I do see the lab charges there, but I'm just pulling up your policy. Um, I know that
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Um, some of the policies have.
[CUSTOMER][NEUTRAL] It says it pays more.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] It says it pays once it says it it pays once a month in the item M in the, you know, in the policy explanations and it says that it's covered only once a month for lab, it has a whole bunch of stuff, but the lab work is included in it. Yes, ma'am.
[AGENT][NEUTRAL] Got it.
[AGENT][NEUTRAL] Yeah. I see it now. So you do, and this is a verification of coverage. It doesn't guarantee the payment of a claim. You do have that lab benefit, but that's only if you're receiving uh chemotherapy, immunotherapy, or uh radiation therapy.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Well, I am, I am having the immunotherapy. That's what I'm having. I, uh, it doesn't mean that if I'm having it right there then because I take it by mouth.
[AGENT][POSITIVE] Exactly.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So it only does it if I have it, if I have it there.
[AGENT][POSITIVE] That is correct. So lab we received.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so what
[CUSTOMER][POSITIVE] Yes, ma'am. Continue. I'm sorry.
[AGENT][NEUTRAL] No, no, that's OK. The labs we received, that was um during the office visit for the uh wellness claim that you've submitted. So, the labs for that is not covered under that benefit. It's only related to that, uh, cancer treatment.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, OK. So what about darling, if you could check, what about the medication that I, I'm taking that I sent in the other week, uh, have they received that or would I, uh, is that not included in my policy?
[AGENT][NEUTRAL] Let me take a look. I do see we received the claim on the [PII]. It hasn't been reviewed just yet. It's in line to be processed. Let me check and see and um.
[CUSTOMER][NEUTRAL] I have a new claim.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] See what we have.
[AGENT][NEUTRAL] Alright, it's
[AGENT][NEUTRAL] Small claims so I could take a quick look at it. Give me one moment.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] And what type of drug is it this? I show up.
[CUSTOMER][NEUTRAL] It's a cancer medication. It's Orthodo is the name of it. Yes, ma'am. That's what they're giving me. I have stage 4 metastatic breast cancer and that's what they changed the medication and so that's what I'm taking now.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Got it. So, I don't show that drug on the list. That doesn't mean that it's not covered. It could be possible that it's um just something that we haven't seen. It could be new, any, any reason. So once this claim is processed, um, we'll do the behind the, the scenes review to see if that drug is covered and would be added to our list.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] So it's hard to give a, a hard yes or no right now. Sorry about that.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK. Well, and, and, and that I hadn't sent any on the two crop that I was taking. I didn't send it in because I didn't know whether it would uh be done. It's, it's a medication that they had started me on, but I had so much.
[CUSTOMER][NEUTRAL] Problems with it although I took it for since January, I mean, I think it was January.
[CUSTOMER][NEUTRAL] Last year, I'm not sure. The doctor changed it when I was uh after they found a spot on my liver or something. I don't remember, but anyway, I was taking that medication and I never turned in anything on it. Would I be able to turn anything in on that one?
[AGENT][NEUTRAL] Let me see. Uh, typically, I would tell you to. Anytime you receive treatment, medicine, uh, related to your cancer, I would suggest that just send that into us and um we'll be able to determine if, you know, it's covered or not, but at least you're not missing out on any benefits. So, um,
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] I would suggest sending it, you said that was for last year. I'm just looking to see if.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, it, well, it was in, uh, it was, they start, he changed it, changed this medication in December. I sent the two prescriptions that I've gotten, but he changed me from the other. I was taking the other for a good while, and it didn't do what he wanted it to do, I guess. And uh I was taking it though. I was, I was prescribed it and getting it every month.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I, and I, and then he, then he stopped it because I, I had a lot of uh what do you call it? uh um what do you call it? um reactions from it, you know, I had the diarrhea was bad and then I broke out in a rash and different stuff like that, but I took it for several months.
[AGENT][NEUTRAL] Got it.
[AGENT][NEUTRAL] Understood. OK. So, what I would suggest um because based on what you're saying, that drug would be in the same drug class of the one that you've submitted, um, that we have on file. I would wait until there's a claim decision on a drug that you filed. If that drug is gonna be paid, then yeah, go back and send in the um information on the other drug.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you so much. Yes, ma'am.
[AGENT][NEUTRAL] Cause I don't want you to have to, you know, go through getting that information and sending and we deny it, you know.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] Well, with the situation like it is, I try to do everything as, as fast as I can because when you have to wait and, and in the situation that I'm in, you know, anything that I can get will help me. Yes, ma'am. So thank you so much for your time.
[AGENT][NEUTRAL] Understood.
[AGENT][POSITIVE] Absolutely, yeah.
[AGENT][NEUTRAL] Oh yeah, no problem, just give it a few more days for this claim to be processed and then you'll know um where to go from there, OK?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] Yes, ma'am. Thank you so much.
[AGENT][POSITIVE] No problem, Mr. [PII]. Is there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, ma'am, that's all. You have a good day.
[AGENT][POSITIVE] Thank you. Thanks for calling ATL. You have a good day also. Bye bye.
[CUSTOMER][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] Yes, ma'am. Bye-bye.