AccountId: 011433970860
ContactId: 12f77ae2-a00e-4fc5-80c8-f7e363e51aac
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1088949 ms
Total Talk Time (AGENT): 375044 ms
Total Talk Time (CUSTOMER): 368214 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/23/12f77ae2-a00e-4fc5-80c8-f7e363e51aac_20250423T13:48_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, sorry. How are you? This is [PII].
[AGENT][NEUTRAL] Oh, hi there. Oh, I'm sorry, you're breaking out a little bit. Can you hear me?
[CUSTOMER][NEUTRAL] Hey.
[CUSTOMER][NEUTRAL] I can hear you. Can you hear me?
[AGENT][NEUTRAL] OK. You're breaking up just a little bit.
[CUSTOMER][NEGATIVE] Oh, I'm sorry. Uh, and then I'm a little bit sick too, so yeah, that's not a good combination. Um, can you hear me better now?
[AGENT][NEUTRAL] Um, I guess it's kind of still cutting out just a little bit. I'm, I'm trying hope maybe maybe when you transfer the call over, hopefully it won't be choppy.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yeah. Yeah. Um, but I have a member, um, that she's trying to check on a claim that she said that she did send a discharge summary and that we're asking for it. It's on the husband. She is the main holder on policy 256-919-99.
[AGENT][NEUTRAL] OK, so she's just asking for claim status?
[CUSTOMER][NEUTRAL] Um, yeah, it's a little bit more than just a claim status. She, she said we're asking for the discharge summary.
[CUSTOMER][NEUTRAL] And she said she already sent that information for the date of service of [PII].
[AGENT][NEUTRAL] OK, let me, I'm sorry, you said [PII]?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, uh, give me just a second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Did she say when she sent the admin discharge summary?
[CUSTOMER][NEUTRAL] She said it was on the, like the first um documents that she sent in.
[AGENT][NEUTRAL] OK, on her initial claim she sent the admin discharge summary?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] She said under the under the first one. So I guess probably the second batch, not really the first one because she said we asked for it one time already.
[AGENT][NEUTRAL] OK, so she's saying that she sent it back in April that.
[AGENT][NEUTRAL] I see that there were 2 submissions, one in January and one in April.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yes, it's gonna be the one in April.
[AGENT][NEUTRAL] OK, let me give me just a second.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and do you have the callback number?
[CUSTOMER][NEUTRAL] I do. Yeah. The callback number is [PII].
[CUSTOMER][NEUTRAL] You need me to repeat it? I'm sorry.
[AGENT][NEUTRAL] Oh, no, I got it. And you said it's Miss [PII] on the other line?
[CUSTOMER][NEUTRAL] Yes, Ms. [PII]. Yes.
[AGENT][POSITIVE] OK, thank you. I can go ahead and uh help her.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] Thank you for holding and being patient for Ms. [PII]. I got Miss uh [PII] on the line. She's gonna assist you from here.
[CUSTOMER][POSITIVE] OK, thank you. You're welcome.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][POSITIVE] Thank you for holding. How can I help you today?
[CUSTOMER][NEUTRAL] OK, so I had some questions. Um, I sent in what I could get on that surgery he had while he was in the hospital. You paid a previous claim for um that [PII] or [PII] hospital visit, but it said on there you wanted him for uh the stuff for the surgery when he had uh his side drained.
[CUSTOMER][NEUTRAL] And then he had a plural window done, uh, I'm not a plural window, a pericardial window done. And so I got what I could and I sent that in, but I don't know why now you're wanting to admit discharge. There wasn't one for that. It was with the surgery thing previously.
[AGENT][NEUTRAL] OK. So you're saying you're just asking what else is needed for the surgery procedure from [PII]?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] Because I got, and it was not easy to try to get all that junk cause like this person changed and this person and then this person doesn't do it, and it's ridiculous.
[CUSTOMER][NEUTRAL] Trying to get the information.
[AGENT][NEUTRAL] Uh, sure, Ms. [PII]. I can take a look at your.
[CUSTOMER][NEUTRAL] Y'all wanted a separate search.
[CUSTOMER][NEUTRAL] Yeah, I wanted a separate surgeon's bill, and they were, they all act like, what are you talking about? I don't know what, and I'm like, OK.
[CUSTOMER][NEUTRAL] I don't know. I'm just telling you what they needed.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure. So yes, for, for, well, for the surgeon bills, um, the reason why we do request those is because it will have the actual procedure codes um for the, the surgery that he, that was performed and so that's how we're able to pay you each of the benefits for the surgery and anesthesia is by having the actual surgeon bills that, you know, provides the information that was performed. Um, so that's the reason for that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, but let me just take a look here and see what else we were needing for, and you said it was the surgery on [PII]?
[CUSTOMER][NEUTRAL] Well, and it was during that time, so the [PII] is when he went in. He had a drain and then like two days later is when they did the surgery for the pericardial window [PII], I guess the [PII].
[AGENT][NEUTRAL] OK, so I just wanna make sure I understand exactly um what procedure were you um questioning for the claim?
[CUSTOMER][NEUTRAL] The pericardio the pericardial window, but you, you put on the ELB you needed an admit and discharge summary for [PII]. You have all of that from the previous claim, so I don't, I'm confused because I was trying to get what y'all wanted.
[CUSTOMER][NEUTRAL] Which was the surgeon's bill, I think it said professional services on it or something.
[CUSTOMER][NEUTRAL] For that one and then I've got questions about the [PII] thing too, so.
[AGENT][NEUTRAL] OK, well, let me take a look at that for you. Do you mind if I put you on hold for just a moment?
[CUSTOMER][NEUTRAL] Um, no, that's fine.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Good morning.
[AGENT][NEUTRAL] Um, but do you mind showing me exactly what, so I have a member on the other line and she's just questioning, she wants to know like, cause she says that, you know, we're, we're asking for the admin discharge summary and so she just want to know exactly what's needed to be able to pay for, I guess, the rest of the surgical procedures from the [PII] through [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, but I see that we paid some procedures. So which specifically are we um
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I just needing more information for.
[AGENT][NEUTRAL] Oh, I can see it.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] So I see that procedure with I guess removing fluid in the lungs.
[AGENT][NEUTRAL] And what type of cancer does he have? Let me see. C92.
[AGENT][NEUTRAL] OK, leukemia. OK. So we're just needing to see.
[AGENT][NEGATIVE] If that's due to his cancer.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, I see.
[AGENT][NEUTRAL] OK, and then I think she has some other question or something on March, but I'll see what her question is, um, but yeah, no, that makes sense. OK, alright, I'll let her know thank you.
[AGENT][NEUTRAL] Bye.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, I'm so sorry about that, Miss [PII]. Are you still there?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, thank you so much for holding.
[AGENT][NEUTRAL] OK, so I did go through all the documents that we had received, and looks like we received some documents on [PII] and on [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And I, I see where we received the, the bills from the facility and the surgeon, but I do not see the admin and discharge summary from the hospital.
[AGENT][NEUTRAL] Um, cause what they're needing to verify is that that procedure that procedure where they were doing the, the drainage, the fluid drainage, if that was due to his cancer or cancer treatment is what we were needing to confirm because the diagnosis codes that were on those bills were not a cancer diagnosis code. They were for different um elements and so that's
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] For COPD.
[AGENT][NEUTRAL] OK. Yeah, so it was this policy.
[CUSTOMER][NEUTRAL] Yeah. See, that's, that's the thing, and I think that's the well, that's the problem we're gonna have is because
[CUSTOMER][NEUTRAL] Uh, one doctor says it's due to his cancer treatment, the medicines, and another doctor says, oh no, it's COPD, so you're not gonna find someone, I don't know what it's gonna say.
[CUSTOMER][NEUTRAL] Honestly.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And he, the pulmonologist that did the draining on [PII] told us that, that it's due to his cancer medicine causing it. But I don't know.
[CUSTOMER][NEUTRAL] How they code anything. You know what I'm saying? I don't know if they share that with their staff. I don't know what, how they do it. So I can get you that stuff. I just don't know what it's gonna show, I think.
[AGENT][NEUTRAL] Yes, ma'am. Uh, so because
[CUSTOMER][NEUTRAL] Cause we were, when we were in the hospital in December, they, they were not sure cause the leukemia started and then all this other happened.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Um, so is that why you're needing the medical records for the [PII]?
[AGENT][NEUTRAL] Yes, ma'am. So because this is a cancer policy, it would reimburse due to the treatment of cancer. And so that's why for the documents, you know, for the procedures that we would reimburse, it would need to have the coding that this is for either cancer treatment or due to cancer treatment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK. All right. Well, I can see what I can get for that. And then um what is the surgery benefit? I, I don't even know. I don't have a book or anything, so.
[CUSTOMER][NEUTRAL] Um, I don't even know what the benefit is.
[CUSTOMER][NEGATIVE] I've just been filing claims and hoping y'all are doing what you're supposed to do, you know what I'm saying.
[AGENT][NEUTRAL] Sure, so you, you can view your policy certificate online on the online service center, um, whenever you're submitting your claims, the policy certificate is available on there as well, uh, just to FYI just for your information that you can see all of your benefits that are covered under your policy.
[AGENT][NEUTRAL] Um, but for specifically the surgical benefit, it does pay a unit dollar amount of $60 per unit, and those units are based upon those CPT codes that are on the surgeon's bill. Those carry a certain value to them.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so it's, you know, it's based upon a unit dollar amount, but the maximum per operation is $6000. So it would depend on, you know, what on the surgeon's bill, those, those CPT procedure codes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, I see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] OK, I'll try to get that in because he uh he had another procedure Friday, another draining, and this time they put in a, a temporary drain so we could drain it at home 3 times a week.
[CUSTOMER][NEUTRAL] And uh and they're trying to get this cleared up so that um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Try to get on top of it cause the spry cell he takes for his leukemia is known to cause pleural effusions. So,
[CUSTOMER][NEUTRAL] So they need to note that somehow that it's in the treatment of cancer.
[AGENT][NEUTRAL] Yes, ma'am. Either it's on like the diagnosis code because, you know, on those bills, those facility bills, there's a section where it has, you know, the diagnosis codes and we, we look there to see if it's, you know, if it has a cancer diag diagnosis code. And if it does
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And then that's when we usually will ask for like an admin and discharge summary because it looks like he was hospitalized during that time and if it states in there that he was being treated for his cancer at that same time, then we can review that for potential benefits. And so that's why that document was being requested.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I need advent discharge for [PII], and is that something because they always send us home with a discharge summary, but is that the same thing?
[AGENT][NEUTRAL] Yes, the admin and discharge summary is what it's called.
[CUSTOMER][NEUTRAL] OK. All right, I'll need to ask for that and I need the medical records for [PII], apparently, I guess on the [PII], if you can look at that, is that the same reason because the codes weren't for cancer treatment?
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] Yes. Yes, ma'am. Um, and so I would just say to them that you need to verify the diagnosis codes for those procedures and, and they should know exactly what that is and be able to provide that document that that states that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. All right, well I'll see what I can get done. It may take me a week or longer because they're not fast.
[AGENT][NEUTRAL] Oh no, that, that's that's fine because as soon as you send it in, uh, we'll just review that, you know, for the prior claims. So it's, it's no rush, um, so, you know, you could just submit it in and, and then we will review that for you, OK?
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][POSITIVE] OK, alright, thank you.
[AGENT][NEUTRAL] Uh, sure, Ms. [PII]. Was there anything else I could do to help you today?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] Thanks for calling APL hope you have a good day.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[AGENT][NEUTRAL] Bye bye.