AccountId: 011433970860
ContactId: 0ffbc712-e7fc-4ae5-a49d-9edda4f6b11e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1450079 ms
Total Talk Time (AGENT): 447099 ms
Total Talk Time (CUSTOMER): 714421 ms
Interruptions: 4
Overall Sentiment: AGENT=-0.1, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/28/0ffbc712-e7fc-4ae5-a49d-9edda4f6b11e_20250528T18:50_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hi [PII], um, I am calling about my dad's um most recent cancer claim that has come through. We have an explanation of benefits and I am an authorized person that can discuss his policy with you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let's take a look. Do we have claim number, policy number? What do we have?
[CUSTOMER][NEUTRAL] Um, whatever you need, the claim number is 360.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] 2856
[AGENT][NEUTRAL] All right. And then if I can get his first name, last name, and date of birth?
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And then what is the address on file?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] All right, thank you
[AGENT][NEUTRAL] OK, so looking at this, it looks like
[AGENT][NEUTRAL] A benefit payment was made for 74,340 on it.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What kind of questions did you have?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So there are lots of comments and I have a couple of questions about these, um.
[CUSTOMER][NEUTRAL] Uh, and here's what I asked. I called the OK, so, um, let me give you a little bit of history. My dad was misdiagnosed for 4.5 years with Bell's palsy or they said it was Bell's palsy and it was really a cancer growth in his face, um, on the one side of his face, attached to salivary gland going up, like, like the whole side of his neck and face cheek up to his skull.
[CUSTOMER][NEUTRAL] Um, they went in and removed that surgically and then or determined that they had left about 2% of it was still there, so they did 6 weeks of radiation. OK, um, radiation just ended last week. So what I sent to you, I called the hospital or UAB who is who is doing it, um, and.
[CUSTOMER][NEUTRAL] They sent me all of their itemized statements.
[CUSTOMER][NEUTRAL] The surgeon is there like everything should I thought should be included in that. So what I had, what I was able to send in this first little batch is through the very first radiation treatment. So all of the surgery, biopsies, all the stuff. OK, as I'm looking at this, I understand that it's saying that the biopsies are not a covered benefit.
[AGENT][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] But I believe
[AGENT][NEUTRAL] Mhm. No, no, go ahead.
[CUSTOMER][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] But I
[CUSTOMER][NEUTRAL] I believe that the surgery itself has some things that would be paid it like anesthesia, something for the um actual surgeon or the actual surgery, but I don't know if you didn't get the documents you were expecting or if they couldn't read it right. It looks like on number 3 it says this claim appears to be a duplication of previously submitted expenses and that should, I mean that's the surgery so.
[CUSTOMER][NEUTRAL] He only had one
[CUSTOMER][NEUTRAL] He only had one surgery where they removed that tumor, that cancerous.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] OK. Let's see.
[AGENT][NEUTRAL] The only other thing I see.
[AGENT][NEUTRAL] OK, so it looks like that date of service was actually submitted when the claim was made for the first occurrence benefit.
[AGENT][NEUTRAL] And it looks like it was denied at that time, just asking for in order to give consideration to this, we need a fully itemized surgery bill that includes a procedure and diagnosis code.
[CUSTOMER][NEUTRAL] OK, let me pull that explanation because I see in order to get some yes, yes, OK, so.
[CUSTOMER][NEUTRAL] OK, I see that. So that's what they're saying it was because we did, we just filed the initial one to get $1000 and I was gonna come back and do, you know, a lot of this other paperwork I had to ask the hospital for it, so I knew that that was coming. OK, so that's why it says it's a duplication, OK, but did I not send what they.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] What you guys need um with the, so this is done at a um University of Alabama Birmingham I guess a hospital and with this hospital itemized bill not be what you need? Do I need to go straight to the surgeon's office and ask them?
[CUSTOMER][NEUTRAL] For something separate?
[AGENT][NEUTRAL] Yes, I would, I would go to, yeah, to them and let them know that you're filing a claim on the cancer policy for him and that the insurance is requesting an itemized bill with diagnosis and procedure codes.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Can you see what I attached for that date on the [PII]? OK, so what is it missing? It's missing the codes or I don't know. I'm trying to read this so it was um because some of the other ones look a little.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah they have.
[CUSTOMER][NEUTRAL] OK, I see so it doesn't have any codes next to any of those descriptions.
[AGENT][NEUTRAL] Oh, then, yeah, that would, that would be, uh, the issue. Most people get confused with procedure and diagnosis cause procedure is the coding for what they actually did and then the diagnosis is what you're being treated for.
[CUSTOMER][NEGATIVE] And that's probably what the lacking.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I will call the surgeon.
[AGENT][NEUTRAL] So we need
[AGENT][NEGATIVE] Yeah, we need that for the surgery and then also the anesthesia. So the anesthesia was denied.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Um, it says please send the surgery charges to include the itemized bill.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, listing the procedure code for this state of service so the benefits can be considered. This bill is obtained from your surgeon's office.
[CUSTOMER][NEUTRAL] OK, I'll have to call them directly and see if they have something separate. I just thought that the.
[CUSTOMER][NEUTRAL] I, I, I thought it was all handled in the same billing office, but maybe they have something separate, um.
[CUSTOMER][NEUTRAL] Alright, now my next question is um.
[CUSTOMER][NEUTRAL] So his policy, it, it, it, it's only covering like the major surgery it's not covering um.
[CUSTOMER][NEUTRAL] Any of the tests like the biopsies is I didn't really see where that was stipulated in his policy, but it might be like in fine print somewhere. But is that, is that correct?
[AGENT][NEGATIVE] I do see that it did deny the biopsy, that the policy provides no benefit for biopsy, it looks like.
[AGENT][NEUTRAL] Um, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and it looks to me like 1 mileage was paid for one trip. It looks to me like that's on the [PII], um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Once this surgical, once I get the surgery.
[CUSTOMER][NEUTRAL] Statements correct? Will they come back and pay that or do I need to notate that? It's um 4 hours away, so they're traveling 4 hours.
[CUSTOMER][NEUTRAL] You know, every time they do this. So that, that date and then it doesn't look like it paid it for that radiation treatment either. So I wasn't sure, it doesn't specifically say it denied it, but they only paid one.
[CUSTOMER][NEUTRAL] I think
[AGENT][NEUTRAL] So it does look like there was a portion paid for radiation.
[AGENT][NEUTRAL] I do see the transportation denial on [PII].
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] It says transportation, no treatment. Transportation and lodging benefit, yeah, it only payable, so.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] There were two other things submitted on that claim for [PII]. 1 was stating that the office visits not covered, and then the other stating that benefits are only payable.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Are not payable for any other disease and cancer or the specified disease. So I don't know if the 127 appointment was something.
[AGENT][NEUTRAL] Not related to it.
[CUSTOMER][NEUTRAL] It was, um, I don't know why it says that. It, it's, it's all related. He went there though.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] For a 114th opinion on this being Bell's palsy. And they, and this guy immediately said, you don't have Bell's palsy. You've got a cancerous growth and they immediately started running tests to see where it's located and how to treat it, you know, how to, how to proceed. So it's all, everything at this particular facility is all related to the cancer.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Um, so I'm not sure why it says that's necessarily, but I know that part of it's a biopsy. They did like a ultrasound guided biopsy also, so they did a couple of biopsies that this says it's not covered, but the surgery will be covered with the anesthesia and that date it doesn't look like any mileage was paid for that date. So that's one that I was wondering about and then the first day of the radiation, the radiation is occurring up there as well.
[CUSTOMER][NEUTRAL] So the first day of the radiation on the [PII], it doesn't look like, I mean, yes, it paid for the radiation benefit, but I was thinking that you get a mileage benefit in addition to that, is that correct?
[AGENT][NEUTRAL] Well, so for transportation I see that there was um a submission for 214 and then the 127.
[AGENT][NEUTRAL] Um, I don't see any other mileage.
[AGENT][NEUTRAL] Transportation on here.
[AGENT][NEUTRAL] The only denial I see was for the 127.
[CUSTOMER][NEGATIVE] Right, it looks like they just didn't pay it and didn't acknowledge it is what how I'm reading it for the for the [PII] and [PII].
[CUSTOMER][NEUTRAL] I wonder if let me pull my attachment because I know I had to put a couple of things down below. I don't know exactly what they were looking at but.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEGATIVE] Yeah, cause I don't even see the submission for the transportation on those dates.
[CUSTOMER][NEUTRAL] You mean on the on the original claim form?
[AGENT][NEUTRAL] Well, on the, the claim that we're looking at, the, the one ending in 2856, the only transportation that I see that was processed or even denied was those two dates. I don't even see any other dates in there.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] Well, that and that's what I was that's what I was questioning because I wasn't sure why now, OK, uh can you see what I originally uploaded I when, when we uploaded his signed claim form on [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It says it's titled [PII] signed claim form 5625. Um, down toward the bottom of that, I drew a red arrow and included two more mileage transportations. I wonder if they just didn't pull that in.
[CUSTOMER][NEUTRAL] That was for the [PII] and the [PII], so maybe I just need to resubmit that and let them consider that.
[AGENT][NEUTRAL] That's what I would do honestly. You don't need to resubmit everything, um, you could just submit that, yeah.
[CUSTOMER][NEUTRAL] Just those two.
[CUSTOMER][NEGATIVE] OK, yeah, I mean, I added it. There were only 3 rows to put travel, so I put the [PII], the [PII] and [PII], and then I drew a line, a red arrow down into the blank space at the bottom of that page and included, I said section C continued and put [PII] and [PII], but it looks like they just totally ignored those whenever they were going through it.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] I'm sorry, yeah.
[CUSTOMER][NEUTRAL] Oh, that's OK. I just, I, I was just, this is the first time we've done this. I'm trying to handle it for him, so I was trying to figure out exactly what I'm doing wrong.
[AGENT][NEUTRAL] Yeah, I see.
[AGENT][NEUTRAL] No, I see what you did. I see the arrow and all that. I don't know why they didn't, um, catch that, but yeah, I would just resubmit it, unfortunately, I'm sorry about that.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, no, that's fine, that's not a problem. Now I mean I've got more, he's like I say he's got 6 weeks of radiation. I've got to submit, um.
[CUSTOMER][NEUTRAL] They paid this radiation with this bill, is that good enough or do you need?
[CUSTOMER][NEUTRAL] What I thought there was something about the insurance, um.
[CUSTOMER][NEUTRAL] Yeah they
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] I don't see any sort of denial on the radiation. It just says that that was the max benefit payable for the date of service, um, but yeah, I mean it looks.
[CUSTOMER][NEUTRAL] So maybe just continue to do that and see.
[AGENT][POSITIVE] Yeah, it looks like it went through just fine. There were no issues on that.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] All right, well, I will, um, I'll call the surgeon's office now and see if I can get a more detailed.
[CUSTOMER][NEUTRAL] Um, statement for the surgery and the anesthesia. Is there anything else? Uh, I'll just ask them everything for that day. I know that you guys paid the $100 for the room, for the hospital stay.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I don't think this policy pays any oh surgery supplies or anything like that. I don't know if it pays anything like that.
[AGENT][NEUTRAL] Let's see if there's anything on the schedule and.
[CUSTOMER][NEUTRAL] That our lab, any kind of lab.
[AGENT][NEGATIVE] No, it looks like labs aren't covered cause that came back is not covered.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Let me see what it says under.
[AGENT][NEUTRAL] Surgery here.
[CUSTOMER][NEUTRAL] I don't know how y'all do this. I'm looking at just one policy. I know y'all look at 100 different variations.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, it's a lot, honestly, and I'll be honest with you, I'm newer to this field um within the last year, so it's, it's a lot to try and break down and
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] And figure out for sure. Um, it does say, I do see here though, it does say under the surgical expense benefit. It says, however, if any procedure code that describes a surgical biopsy, this is not an insured benefit. So, it does state that. Um,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Oh gosh, didn't have procedure code. OK.
[AGENT][NEUTRAL] I'm not seeing anything yet about supplies, and I didn't see anything that spoke to supplies under like any sort of drug benefit or, you know.
[AGENT][NEUTRAL] Anything like that, medical equipment.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yes, and he's also getting home help right now so I don't know how to do that either. I can do that later I guess but I really don't know how to navigate that one.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So it does pay.
[CUSTOMER][NEUTRAL] It's listed in here.
[AGENT][NEUTRAL] Uh, the home health.
[CUSTOMER][NEUTRAL] It says yeah, home recovery benefit but then.
[CUSTOMER][NEUTRAL] That says equal the number of days in the hospital. I don't know what that is, but skilled nursing home, and extended care actual charges not to exceed $50 per day.
[CUSTOMER][NEUTRAL] Uh, uh, oh, there's more details.
[AGENT][NEUTRAL] So there's a couple different things because I was scrolling back up towards home health. Let me go back up there, we'll go there first and then come back down. Let me see.
[CUSTOMER][NEUTRAL] to
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Home health, you would have to be, you would have required.
[AGENT][NEUTRAL] Yeah, it looks like the home healthcare services is, if it's provided by a licensed home healthcare agency on a part-time or intermittent basis while you are confined to your home because of cancer.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and then it does also talk about like private nursing benefit.
[CUSTOMER][NEUTRAL] I'll, I'll do.
[AGENT][NEUTRAL] But so it says if as a result of cancer, if an insured person incurs an expense for a full-time private care and attendance of a nurse, that expense oh that's while confined in a hospital as a result of inpatient.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sounds like that's more inpatient.
[CUSTOMER][NEUTRAL] Yeah, no, this was actually ordered by the um doctors after he got home. I, I think there's probably it's gonna be something like that per day, something.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I, I'll, I'll tell you what, I'm gonna get through the radiation and then I'll handle the home help at the end, but I did wanna ask you, they've had to order some uh walker and a couple of things, not, not super expensive, but it looks like I saw up to $500 every 5 years or something. What do you need for that, um, to file like what kind of support do you need?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let's see what they ask for. Yeah, no, that's true. So it does say medical equipment includes braces, crutches, wheelchairs, oxygen equipment, respirators, any medical uh devices, all when prescribed by a physicians, so.
[CUSTOMER][NEUTRAL] Mhm OK.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Ah
[AGENT][NEUTRAL] So when filing a claim for any medical equipment, they asked for an itemized invoice or itemized receipt.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that's all it states.
[CUSTOMER][NEUTRAL] OK. So no kind of like doctor's note or prescription or anything like that, OK.
[AGENT][NEGATIVE] Doesn't look, it doesn't look, doesn't look like it, doesn't look like it.
[CUSTOMER][NEUTRAL] OK, OK, cool, alright, well I guess I mean I can submit and resubmit as many times as I need to, right? So just submit what I think is right and then when it gets kicked back I can reply and say OK here's where I'm fixing it OK OK well we'll just.
[AGENT][NEGATIVE] Yeah, no.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Yeah, absolutely, and
[AGENT][NEUTRAL] I was gonna say cause these ones are just tricky. It's a lot of information, honestly, you're not the only one, trust me.
[CUSTOMER][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] Right, well, and, and it's, you know, it's really easy to misconstrue some of it because honestly this, he sat with this, as I said, misdiagnosed for 4 years so it impacted his teeth, his jawbone, his eye, his hear I mean like there's so much that.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] An outsider could look at and say, oh, the doctor's treating something different, but it's all related to the cancer. So, yes. Um, so I'll just send it and then we can go back and forth once I do, but I really was not sure about the surgery because I do think that's gonna be a, a.
[AGENT][NEUTRAL] Mm.
[AGENT][NEGATIVE] Related. Gotcha.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You know, uh, it's pretty fairly substantial payout, so I don't know, I was trying to get that right.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right, right.
[AGENT][NEUTRAL] I hear you. I hear you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, I'll call the surge and see what I can get and we'll get that resubmitted to you.
[AGENT][POSITIVE] OK, sounds good. Anything else?
[CUSTOMER][NEUTRAL] Um, I think that's it.
[AGENT][POSITIVE] All right. Well, definitely give us a call back with any other concerns or questions. Happy to help.
[CUSTOMER][POSITIVE] Thank you, appreciate it.
[AGENT][NEUTRAL] Yeah, bye-bye.