AccountId: 011433970860
ContactId: 14ea97b6-24ce-422b-9c7c-6eeb235947c6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1472160 ms
Total Talk Time (AGENT): 628223 ms
Total Talk Time (CUSTOMER): 727646 ms
Interruptions: 10
Overall Sentiment: AGENT=0.1, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/06/14ea97b6-24ce-422b-9c7c-6eeb235947c6_20250606T21:40_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], I was wondering if I could speak to someone to.
[CUSTOMER][NEUTRAL] Um, get some clarification concerning some claim amounts.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And this is in regards to a patient or yourself?
[CUSTOMER][NEUTRAL] Myself.
[AGENT][POSITIVE] All right, I can help you with uh claim status. Can I get your name and a good call back number in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure. It's [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And what's your policy number?
[CUSTOMER][NEUTRAL] It is 138.
[CUSTOMER][NEUTRAL] 648-0.
[AGENT][NEUTRAL] 648-0
[CUSTOMER][NEUTRAL] Yes, uh huh.
[AGENT][NEUTRAL] OK, give me just a second.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] And can I get you to verify your date of birth for me please?
[CUSTOMER][NEUTRAL] Sure it's [PII].
[AGENT][NEUTRAL] And address that we have on file?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you so much for verifying that. Do you have the claim numbers or the date of service?
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Yes, I do.
[AGENT][NEUTRAL] Either one will work.
[CUSTOMER][NEUTRAL] OK, um, and, and understand that in asking about these I'm, um, I'm not saying.
[CUSTOMER][NEUTRAL] That you all did anything wrong or that there's anything wrong at all. It's just that there were 7 claims and 3 of them came back in exactly the amount they thought they would, but 4 of them were slightly different and the, the thing about the claims unless there's and, and maybe there is some way that I can um find out online like the explanation of the amount that was paid but I, I, I couldn't really figure out the explanation.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And that's why I was just gonna ask about these 4 to try to understand why the numbers are a little bit different than what I thought they might be.
[AGENT][NEUTRAL] OK, uh, let's let's go one by one. What's the first one?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, I believe this is the letter O and not the number 0, but I'm not sure, SC.
[CUSTOMER][NEUTRAL] 97785
[AGENT][NEUTRAL] OK, and that is the confirmation number OSC 99 or I'm sorry 97785, correct? That's OK. I can see it. I can see, OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Yes, and you know what you're OK I do see I told you the confirmation and not the claim um I will give you the claim on the other ones. I'm sorry about that.
[AGENT][NEUTRAL] Yeah, that's OK. Either one and it works for me. I can see both of them, uh, and you were wanting to know about the payment for that one?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh. The only question I had on this one is that I, uh, supplied the, the documentation for uh 5 PSA tests which were diagnostic in nature, um, because of my prostate cancer, but only received a payment for 4 and wondered if.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If you could clarify why the the 5th 1 might not have qualified.
[AGENT][NEUTRAL] OK, let me look.
[CUSTOMER][NEUTRAL] Because if I, I believe they were each in a different year. I, I got way behind on doing any kind of claims and hadn't done any kind of claim filing for.
[CUSTOMER][NEUTRAL] A long time I think 5 or 6 years and so um I had a big year full of all sorts of things last year and then going in to file for some of the bigger things like surgery I was going back and getting some of the things that I hadn't done in past years as well.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Um, it looks like one of the treatments.
[AGENT][NEUTRAL] It shows that the diagnostic and prevention benefit has been exhausted for that calendar year. Um, I can go into further detail on that. It just shows that there's no further benefits available for that screening and then the other two that were denied.
[AGENT][NEUTRAL] Was, um, it looks like a medical imaging.
[AGENT][NEUTRAL] Code and it was that you had met the calendar year maximum for medical imaging.
[AGENT][NEUTRAL] And then what was the other denial?
[AGENT][NEUTRAL] OK, and the denial for what looks like a surgery or a pathology or some type of surgery, it looks like in order to uh give consideration to that procedure, you need to send the pathology report for that date of service and I'm showing the date of service was.
[AGENT][NEUTRAL] [PII], so you just need to send in the pathology report for that one.
[CUSTOMER][NEUTRAL] OK, and, and is that all in regards to this one claim or is that in regards to some of the other claims, um.
[CUSTOMER][NEUTRAL] Because maybe you might be answering um multiple que I had 4 questions and you may you might be answering more than one question right now. I just wanted to make sure is that all with just this one claim or is could that be any of the other claims too that you're talking about?
[AGENT][NEUTRAL] Yeah, um, I'm showing, cause you were talking about you had, uh, what was it 4 that were paid and one that wasn't. And it looks like I have 1235, of those treatments in the same claim and only one of them denied, so it, it sounds like we were talking about the same.
[AGENT][NEUTRAL] The same one because I have data services dating back from [PII], [PII], [PII], 24, and 25, and it looks like.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And can you tell me the one that was already um you said that one had already been supplied for one of those years, can you tell me which year that was?
[AGENT][NEUTRAL] Uh, the one that got denied was for [PII].
[CUSTOMER][NEUTRAL] OK, and that's because they already had a PSA claim either earlier or later in that year.
[AGENT][NEUTRAL] So it would have been earlier because it's showing that the benefit for that prevent or for that benefit was exhausted for that calendar year um so it probably would have been something earlier in the year that you submitted.
[AGENT][NEUTRAL] Because it looks like you submitted most if not all of your claims, so you, we can go back and look in a moment if you'd like, but it looks like the one for uh [PII] June you had already used up the diagnostic benefit.
[CUSTOMER][NEUTRAL] OK, do, do you see something earlier in the year, um, and, and I'm, I'm, I'm about 99% sure you, you, you are right, and you know uh more about this and that than, than I do, um, but can you tell me like what was the, the claim, the date of the claim and what was the actual claim earlier in [PII] that caused the [PII] to be denied?
[AGENT][NEUTRAL] Um, I can look at that. Um, but I will say, um, if you need to write it down, uh, don't forget to send the pathology report for that one for, um, 1128 23 for that. Uh, it was either, it looks like it was a surgery or something. Um, so that one only got denied and it's all in the same claim. This one is just the same claim. Um, bring it, submit that pathology report with this claim number.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, ending in 0414. Go ahead and send in the pathology report for that one and see if you can get some, some benefits in for that one.
[AGENT][NEUTRAL] Um, but let me go back now.
[CUSTOMER][POSITIVE] Thank you thank you very much because I didn't even in sending in what I sent in I didn't even know that I might qualify for that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] That particular claim, so thank you for your help.
[AGENT][NEUTRAL] When in doubt, just send everything. We review everything, uh, whenever you submit a claim and you review uh whether you send in two pieces of paper or 20 sets of paper, paperwork, uh, our claims department reviews every single document. So when in doubt, I mean the worst that can happen is it gets denied and you need something else, uh, to, to complete it, but when in doubt, just go ahead and send it. Uh, it can't really hurt to send it in and check. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Hey thank you.
[CUSTOMER][POSITIVE] Thank you for that advice. I appreciate it.
[AGENT][NEUTRAL] And let me see.
[AGENT][NEUTRAL] Let me see if I can figure out the other one.
[AGENT][NEUTRAL] For you.
[CUSTOMER][NEUTRAL] I bet what might have happened on the other one is what just happened with this one on the pathology report is that maybe it was already included in another claim and I didn't even know that it was included in another claim like I didn't even know that this particular claim had the potential for maybe getting a claim related to the pathology report so I that's probably what's going on here is that maybe something else I sent in um.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Although I, I sort of sent everything in at one time just recently because I hadn't seen anything in for like 5 years, but maybe there's something else and one of the other things that I sent in that I'm just not aware of that maybe they.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, um, I'm not able to see it because I tried looking for it by that procedure code and then unless I know the exact procedure code, I'm not able to search it.
[AGENT][NEUTRAL] Um, let me see.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Cause I, I thought, but I could be wrong like I, I thought that the only thing of the claims, and I won't be asking you at all about three of the claims because they turned out exactly like I thought they would, um, but on the other claims I don't think any of them had anything to do with uh PSA diagnostic testing, but I, but I could be wrong.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I probably am wrong because I, I would imagine your records are are better than mine in terms of all the details of this.
[AGENT][NEUTRAL] Um, I was able.
[CUSTOMER][NEGATIVE] It's a little overwhelming to me because there's so so much stuff.
[AGENT][NEGATIVE] I was able to look for that PSA code and I couldn't find it, um, anyone other than that one that got denied, um.
[AGENT][NEUTRAL] And remind me again because I've, I've already switched to a different screen. What was that PSA for? Was it a treatment?
[CUSTOMER][NEUTRAL] Uh, no, it's a, it's called a prostate antigen test, and although they did them multiple times during the year to to monitor my cancer, um, they, um, I only sent in one per year because they told me that was the max that they could reimburse was one per year, so I thought I sent in like one for 20.
[AGENT][NEUTRAL] OK, so it was a diagnostic test?
[CUSTOMER][NEUTRAL] [PII] and [PII] and [PII] and [PII] and [PII] and it it looks like according to to what you said that they reimbursed 4 out of those 5 but they didn't reimburse the one in [PII] because it sounds like you said that maybe there was already um it had already been met or already been.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, and so,
[CUSTOMER][NEUTRAL] Used and I was just trying to understand because I I don't think I did any other PSA diagnostic testing on any of the other claims.
[AGENT][NEUTRAL] Yeah, so for [PII].
[CUSTOMER][NEUTRAL] In [PII], like I thought I did.
[AGENT][NEUTRAL] It would be, um, so I do see the PSA on here for diagnostic testing. It could have been anything from um a chest X-ray, um, any type of colonoscopy, virtual colonoscopy, uh, blood test, ultrasound, anything like that could have been covered, or any sort of follow-up testing. So maybe it might not have been the code for a PSA. It could have been something, some other type of testing.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You know what then?
[CUSTOMER][NEUTRAL] And you know what? I think you're, I think you are.
[CUSTOMER][NEUTRAL] I think you're right and I think now let me get to because there were 3 other claims and they did have other things like I was just thinking that the PSAs were the diagnostic but a couple of them do like one does involve a colonoscopy and one does involve um a CAT scan and maybe those were considered diagnostic although I thought those were considered um imaging.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Although like I wasn't quite sure and I sort of did what you said. I just sort of send in everything and I wasn't sure like what qualified for what or or what it would be.
[CUSTOMER][NEUTRAL] Considered so uh let's go ahead and look at the other three and maybe as we look at the other three it'll be clear to me that oh that's where that other one is that that that caused this one to be denied and you know what, maybe let's go let's look at claim 360,410.
[AGENT][NEUTRAL] So, um,
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Because it does have a $50 amount in it and maybe that's where it is and and maybe it is the colonoscopy just like you just said.
[AGENT][NEUTRAL] 40, OK.
[AGENT][NEUTRAL] Yeah, I do see the colonoscopy on there and I will say since I do see that you're submitting this through your online portal if you ever um don't know which testing is covered, if you go into your portal and go into I believe it's um.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] My details or um let me see what is it called exactly.
[AGENT][NEUTRAL] Uh, you should be able to view, oh.
[CUSTOMER][NEUTRAL] Oh, so there is a place that.
[AGENT][NEUTRAL] So have you logged in since Monday? Have you logged in since Monday?
[CUSTOMER][NEUTRAL] That breaks it down and explains it?
[CUSTOMER][NEUTRAL] I just did um earlier today and everything looks sort of different.
[AGENT][NEUTRAL] OK, OK, that's going to be one thing that we need to to get taken care of, um.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and then I can, I can kind of give you a, a heads up on like how to, how to help for future, um, claims as well. So we just got a new online service center portal we, we got a new platform so even though you had an account in the past, you will go to the same website [PII], but you will click on create OSC account.
[AGENT][NEUTRAL] You'll put in um the same oh uh-huh.
[CUSTOMER][NEUTRAL] And I did that
[CUSTOMER][NEUTRAL] And I set up a whole new thing and and now I do have access to my new dashboard, so I do see like everything looks a little different, mhm.
[AGENT][NEUTRAL] OK, so on your dashboard.
[AGENT][NEUTRAL] OK, so on your dashboard.
[CUSTOMER][NEUTRAL] And I do see my details.
[AGENT][NEUTRAL] Good good OK yeah there should be something on the dashboard it'll look like two hands holding a heart and it'll be my policy details, excuse me, my policy details.
[AGENT][NEUTRAL] And you'll go into your policy and if you look on page I believe it's 14 under section 5 benefits it has a list laid out under section A of every test that will count towards your uh diagnostic testing, so colonoscopy and virtual colonoscopy are on there.
[CUSTOMER][NEUTRAL] OK, and so that's likely where that other $50 is, I mean that's why I did. OK, then could you explain to me the like I got $550 on that claim $3,600,410 and so $50 of it is the colonoscopy for diagnostic and then the what's the other $500 is that for the anesthesia?
[AGENT][NEUTRAL] That's what it looks like, yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, it looks like you had a CAT scan.
[AGENT][NEUTRAL] Or some type of imaging?
[CUSTOMER][NEUTRAL] Yes, I did.
[AGENT][NEUTRAL] It it went towards that.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, but I showed that one as my as a different claim 3,600404 and I do see the $500.
[CUSTOMER][NEUTRAL] There, although you know what, maybe I had multiple CAT scans. It's sort of hard to remember all the different things that went on. Like I do show that I got $500 for 3,600404 claim. There was a CAT scan and a biopsy.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, but it looks like there's like another $500 benefit in the 3,600,410 that I wasn't sure, um, what it was actually I thought that $500 was for the colonoscopy, but it sounds like actually the $50.
[AGENT][NEUTRAL] No, that's for the imaging because it's a medical imaging one. So the medical imaging is 500.
[AGENT][NEUTRAL] So if you see a charge for 500, it's likely for the for some type of imaging like the CAT scan or the PET scan.
[CUSTOMER][NEUTRAL] And that's OK.
[CUSTOMER][NEUTRAL] OK, and so is there a chance then that on the 3,600 410 that the reason it's 550 is because it was imaging and it was diagnostic in nature like is that where they're coming up with the 550?
[AGENT][NEUTRAL] Uh, so that claim ending in 410, you got the 50 for the colonoscopy and the 500, uh, for the imaging. I can't remember what the other claim number was that you said. What was the other one that you said that you.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] It's uh 360404.
[AGENT][NEUTRAL] OK, let me look at that one real quick.
[CUSTOMER][POSITIVE] Thank you very much.
[AGENT][NEUTRAL] So yes that's a diff that's that was for [PII] again that one is just 500 and that was again for imaging.
[CUSTOMER][NEUTRAL] OK, so, OK, then that address is the.
[AGENT][NEUTRAL] So it was another one of those medical imaging tests.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Alright, thank you. You've cleared up 3 of my 4 questions and I'm down to the last one. Thank you for your patience and explaining because I, I thought that's probably what was going on is I just didn't quite understand the only other question I had and it's not even a question about the um.
[AGENT][NEUTRAL] Oh, anytime.
[CUSTOMER][NEUTRAL] I'm, I'm not questioning anything except I'm just trying to understand where the number came from, so just like you told me on the last one that it was $500 for imaging plus 50 for diagnostic, can you explain claim 3,600392 and how they came up with the the 20091 amount? I'm just trying to understand, um, because of those when I, I looked on the uh let's see where is that?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I looked on the surgical benefit one under under my schedule of benefits.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And it said that there was a maximum of $3000 but then I also noticed that there was um.
[CUSTOMER][NEUTRAL] $100 per day of confinement and I was in the hospital for 3 days and and the actual.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Amount I think was like, I don't know 30 $35,000 was the total bill.
[CUSTOMER][NEUTRAL] And then there was and I was in the hospital for 3 days, but I, I think I'm trying to oversimplify it because I, I thought that since the surgery itself was in the $30,000 range that I might get the $3000 maximum for operation and that since I was in the hospital for 3 days that I might get 3 times $100 for the 3 days I was in the hospital but.
[CUSTOMER][NEUTRAL] I don't know and was wondering like how did they come up with that 2091 and then that's my only other question for today and I appreciate it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So when you're looking at your surgical benefit and I have it still pulled up, it shows the unit dollar amount, so $30 and it's a maximum per operation of $3000 so it would have been how they coded it, um, so it goes based off of unit. So that would mean that you would get up to, I believe I'm horrible at math, 100 units is how much it's allowed. So that 3000 comes from the units that's in the procedure that they coded um and I'm not able to see the unit numbers.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But I can tell you a little breakdown of it. Um, I am seeing a $300 benefit and that looks like it was for the confinement that you were talking about, uh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, that part makes good sense to me then.
[AGENT][NEUTRAL] It looks like something related to drugs or some type of um drugs and medicine. It looks like you got $150 for that, which would have been uh for your inpatient confinement, you get $150 for that.
[AGENT][NEUTRAL] Uh, $300. It looks like it was related to some type of blood work that you had done. Uh, you're allowed $300. 0.
[CUSTOMER][NEUTRAL] Wait, I'm sorry, did you say 300 on the blood work? OK, OK.
[AGENT][NEUTRAL] Yes, um, because your maximum is for blood, plasma and platelets is $300 a day. It looks like they did that for 1 day.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Your surgery benefit based off of the units that they coded to us, you got $1700 I'm sorry, $1,072.80.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] And let me see what else. Um, you also had, it looks like anesthesia. Um, let me pull that one up and see what it would be.
[AGENT][NEUTRAL] It looks like your anesthesia benefit is percentage, so it's at 25%.
[AGENT][NEUTRAL] Um, and that's why we gave an amount of $268.20.
[AGENT][NEUTRAL] And then it looks like there was one other type of surgery, um.
[AGENT][NEUTRAL] Let's see what that one is surgery RV.
[AGENT][NEUTRAL] Don't quite know what that one would be.
[CUSTOMER][NEUTRAL] You know what? I think you're actually already at my that 2091.
[CUSTOMER][NEUTRAL] Because I'm adding up, you said $300 for confinement plus $300 for blood work plus $150 for drugs that gets me up to $750 plus the $26,850 or $20 you just said on my uh anesthesia and that gets me just over $1000 and then I add that just over $1000 to you said I got 1,007,280 for my.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Surgery benefit and that gets me to 2000 right at 2091 so I guess that I guess the only thing at huh.
[AGENT][NEUTRAL] So it looks like the only thing that we denied oh go ahead.
[CUSTOMER][NEUTRAL] OK. No, no, no, you go right ahead.
[AGENT][NEUTRAL] OK, so I'm just gonna read this out.
[CUSTOMER][NEUTRAL] I, I was just gonna say the only thing that I didn't understand.
[CUSTOMER][NEUTRAL] I'm you go right here.
[AGENT][NEUTRAL] I'm so sorry. I think that there's a lag in, in our, our phones, so, um, I was just going to tell you why uh the other surgical benefit got denied. It looks like it's payable once per operation. Um, so 2 or more, 2 or more surgical uh procedures performed through the same incision are considered one operation. So that's why the other one got denied, um.
[CUSTOMER][NEUTRAL] No, you're fine.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Because they did uh a surgery through the same incision. So that's the only thing that got denied on that claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you for explaining everything to me and thank you for your patience and answering all my questions. I sure appreciate it.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Anytime. It's, it's confusing. I get it.
[CUSTOMER][POSITIVE] You have a nice weekend. Thank you.
[AGENT][POSITIVE] All right. You too. Stay safe.
[CUSTOMER][POSITIVE] Uh huh thank you bye bye.
[AGENT][NEUTRAL] Right bye