AccountId: 011433970860
ContactId: 0d1d0c1e-e605-41b4-8bc0-c13cd2f96e62
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 889500 ms
Total Talk Time (AGENT): 270879 ms
Total Talk Time (CUSTOMER): 225510 ms
Interruptions: 1
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/15/0d1d0c1e-e605-41b4-8bc0-c13cd2f96e62_20250415T20:04_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] in Medlink. I have policy number 1220189.
[CUSTOMER][NEUTRAL] For part one, Renee.
[AGENT][NEUTRAL] Is it
[AGENT][NEUTRAL] Is this for Spanish speaking?
[CUSTOMER][NEUTRAL] Um, he calls the Spanish name. He speaks English.
[AGENT][NEUTRAL] Oh, OK, OK, just making sure cause I, I don't know why it rolled to rolled to us. Um, OK, um, what was that policy number again? I'm sorry.
[CUSTOMER][NEUTRAL] 1220189
[AGENT][NEUTRAL] OK, and the member?
[CUSTOMER][NEUTRAL] Renee.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, so he has some questions on his claim that was denied and then he also has questions on the benefits.
[AGENT][NEUTRAL] OK, you can transfer him on through.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Hi, this is [PII]. Can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], yes, I want to review a claim with you, um, that I received.
[AGENT][NEUTRAL] OK, is it for yourself?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And what was that date of service?
[CUSTOMER][NEUTRAL] The date of service from date is that the one or the date received that you guys received it?
[AGENT][NEUTRAL] Uh, it would be the other date. Yeah. So the actual date you saw the doctor or provider.
[CUSTOMER][NEUTRAL] Yes, um, it is from [PII].
[AGENT][NEUTRAL] OK. And how can I help you?
[CUSTOMER][NEUTRAL] All right, so.
[CUSTOMER][NEUTRAL] In here, um, I submitted with that claim.
[CUSTOMER][NEUTRAL] The documents from um the provider from Caremark, um.
[CUSTOMER][NEUTRAL] Both the bill uh for the dates that were uh from [PII] to uh.
[CUSTOMER][NEUTRAL] [PII] from CVS Specialty, and that was supposed to be for the uh chemo radiation or immuno benefit uh that I had with you guys with the policy that ended in 189.
[CUSTOMER][NEUTRAL] Now it says that there needs to be uh that I need to provide copies of your explanation of update.
[AGENT][NEUTRAL] Um, yeah, it's explanation of benefits. I don't know why it says update. Um, it just be your EOB from who, who is your primary insurance? Is that?
[AGENT][NEGATIVE] Well, I actually, I don't think I need.
[CUSTOMER][NEUTRAL] It, it was, yeah, it was Caremark, um.
[CUSTOMER][NEUTRAL] For all of those um.
[CUSTOMER][NEUTRAL] Uh, medications because it's a specialty, uh, term marks, yes.
[AGENT][NEUTRAL] OK, let me, let me pull up your policy real quick. This will help.
[AGENT][NEGATIVE] I don't know why I do that.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so this was like specialty drugs for chemo, is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's
[AGENT][NEUTRAL] OK, give me just one moment pulling these up to see what we received, um.
[AGENT][NEUTRAL] 3
[CUSTOMER][NEUTRAL] Yeah, of course.
[AGENT][NEUTRAL] OK, I see the claim that you had submitted and uploaded on our portal.
[AGENT][NEUTRAL] Um, let's see, listing all of the
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The dates and charges, let me see what we're missing.
[AGENT][NEUTRAL] OK, I see, I see it listed out of what, what they did, but I don't see a diagnosis listed, um.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Um, that, that would be found in earlier, um.
[AGENT][NEUTRAL] Miss.
[CUSTOMER][NEUTRAL] I guess claims.
[AGENT][NEUTRAL] OK, let me see if if we have that on file. Let me see.
[CUSTOMER][POSITIVE] No worries.
[AGENT][NEUTRAL] OK. Um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Just looking through, bear with me. Hold on one moment.
[CUSTOMER][POSITIVE] Yes, no worries. Take your time.
[AGENT][NEUTRAL] We got a listing from CVS and then we got a listing from
[AGENT][NEUTRAL] The [PII], um, so I'm trying, I'm trying to locate the
[AGENT][NEUTRAL] Um, let's see here.
[AGENT][NEGATIVE] It's not.
[AGENT][NEUTRAL] OK, everything I'm seeing here, we, we have 3 different submissions.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] Mhm, yeah, correct, it, it went to the wrong um policy.
[AGENT][NEUTRAL] I don't
[AGENT][NEUTRAL] Oh, OK, um.
[AGENT][NEUTRAL] You, you wanted this submitted to your group cancer, is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, because everything, the 3 submissions that we received, um, basically just list out the charges for the um chemo drugs and the um
[AGENT][NEUTRAL] But I, there's no diagnosis anywhere on these submissions.
[AGENT][NEUTRAL] So that's, that's what we're needing is the diagnosis.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So, yeah, one second.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Checking uh.
[CUSTOMER][NEUTRAL] OK, so the claim that was submitted, um, I mean I have the number it was 313-535-5.
[AGENT][NEUTRAL] Yes, I see that for MD [PII].
[AGENT][NEUTRAL] And that we paid out on, but we can't use that submission for these claims.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So it has to be, so what you've submitted.
[AGENT][NEUTRAL] For the, for the chemo drugs.
[CUSTOMER][NEUTRAL] I need a diagnosis.
[AGENT][NEUTRAL] Yeah, but we, we have to have like.
[CUSTOMER][NEUTRAL] But there, there was a
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] That, that wasn't there already a diagnosis that was submitted uh in order to receive the benefits for the surgery?
[AGENT][NEUTRAL] We correct, but when you submit claims for reimbursement for a particular benefit, like you're wanting reimbursement, your policy will pay out for chemo.
[AGENT][NEUTRAL] But we have to the diagnosis on the submission with those charges.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So everything on here lists all of the charges and what type of drug was administered, but it doesn't say anywhere what the diagnosis was.
[AGENT][NEUTRAL] Um, so,
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So can we use the one from the claim that I mentioned, the one that ends in uh 355 to, it's the same diagnosis, it's the same uh policy number.
[AGENT][NEUTRAL] Um, I, I don't think that we can, but I can get you over to our claims department. I, we just, I just do claim status. I can review the claims that we received.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I think it has to include in the documentation that you submitted has to actually include the diagnosis, but I can transfer you to our claims department. Do you want me to transfer you over there?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK, thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], this is [PII] on the care team. I've got a member that um wants to, I've been going through his claims with him, but he wants to know about a diagnosis if it can be pulled from a different claim for other claims we denied, so.
[CUSTOMER][NEUTRAL] Alright, what's his policy number?
[AGENT][NEUTRAL] Policy number is 1220189.
[CUSTOMER][NEUTRAL] OK, and the patient's name and date of birth?
[AGENT][NEUTRAL] Uh, patient is
[AGENT][NEUTRAL] [PII], [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I've got the claim numbers.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] He's asking about a diagnosis code?
[AGENT][NEUTRAL] So there's 3 claims for chemo drugs that he submitted.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] And it has the listing of the chemo drugs and the bill charges, but there's no diagnosis listed on the claims itself.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So he's saying can we reference the claim that we paid out on for him?
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] But I didn't think that we could, and
[AGENT][NEUTRAL] Yes, documentation.
[CUSTOMER][NEUTRAL] OK, give me one of the claims, give me one of the claims number he's questioning.
[AGENT][NEUTRAL] You know, that have
[AGENT][NEUTRAL] 321-655-57.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] And the date, the date of service.
[AGENT][NEUTRAL] I guess it's uh well [PII] and then [PII] [PII] and then [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's the chemo is what he's questioning the chemo charges.
[CUSTOMER][NEUTRAL] Just to get clean.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] One second, trying to get my little ducks in a row.
[CUSTOMER][NEUTRAL] OK. It looks like with the chemo charges we're needing the explanation of benefits from his um.
[CUSTOMER][NEUTRAL] The primary carrier.
[CUSTOMER][NEUTRAL] But you can send him over.
[AGENT][NEUTRAL] OK, I didn't know, do they require explanation of benefits? I thought that was only on Medlink.
[AGENT][NEUTRAL] I
[CUSTOMER][NEUTRAL] No, on some of the cancer policies they have to have the explanation of benefits because we paid the um the actual charges and so the explanation of benefits usually will have the actual charges.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK, OK. All right. I'm gonna send him on over to you, OK?
[CUSTOMER][POSITIVE] Alright thank you [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Good afternoon. Thanks for calling AP