AccountId: 011433970860
ContactId: 1b74a68f-8456-4e80-b333-c6bf6f80c424
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1205920 ms
Total Talk Time (AGENT): 485816 ms
Total Talk Time (CUSTOMER): 418052 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/21/1b74a68f-8456-4e80-b333-c6bf6f80c424_20250221T14:05_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling American Public Life. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] on the care team. How are you?
[AGENT][POSITIVE] I'm just fine, thank you.
[CUSTOMER][POSITIVE] That's good. Um, I have a.
[CUSTOMER][NEGATIVE] Insured on the other line. She's upset. She's just getting herself upset. Basically, she has a cancer policy. There's two different cancer policies. Um.
[CUSTOMER][NEUTRAL] She wants to know why one claim was paid 11,000 versus 800. We paid the actual charges. She's not understanding what actual charges are. I'm trying to explain to her we paid what we were billed, um, but she just keeps getting herself upset saying that she wants me to compare and um tell me which bills or tell her which bills, um, so she just needs to speak with someone in claims more in depth with her, uh, OK.
[AGENT][NEUTRAL] OK, what is her policy number?
[CUSTOMER][NEUTRAL] So the first one, I'll give you the one for the 11,000, it's 242-6704.
[AGENT][NEUTRAL] And her name is [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, getting with.
[CUSTOMER][NEUTRAL] And it's OK.
[AGENT][NEUTRAL] And that is her GC 14.
[AGENT][NEUTRAL] And then she has the GC 7002. Is that the claim that she's on? I, I don't know.
[CUSTOMER][NEUTRAL] Well, hold on. So the, the, OK, wait, so the GC 14, we're looking at claim number 3422156, I'm sorry, 3422156 is under part two.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, this is her husband, correct? OK, hold on here. She, I think I.
[CUSTOMER][NEUTRAL] Yes, mhm.
[AGENT][NEUTRAL] She gets very.
[AGENT][NEUTRAL] Hold on.
[AGENT][NEUTRAL] I mean like I'm, I'm pulling things up.
[AGENT][NEUTRAL] So this is on [PII]. OK. Now, hold on, let me get the other one up.
[AGENT][NEUTRAL] I think I have spoke with her before. She's
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] It's mad very easily.
[AGENT][NEUTRAL] And you can't explain anything to her because she's always very.
[CUSTOMER][NEUTRAL] She's just ready.
[CUSTOMER][NEUTRAL] I just have to say, OK. I, I.
[AGENT][NEUTRAL] I know.
[AGENT][NEUTRAL] I'm sorry, let me, I want to pull things up before I
[CUSTOMER][POSITIVE] Oh no, you're fine. Yes, get all the ducks to the row.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] No, I don't think I spoke with her. She's not the one I'm thinking of, thank goodness. OK, so hold on here. Let me.
[AGENT][NEUTRAL] So which um which client number?
[CUSTOMER][NEUTRAL] So under the, the GC 7002?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] We're looking at that last claim, um 356-660-9.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So her argument is why is this one being paid 82266 and the other one on the other policy was paid 11,000 and I'm trying to explain to her that one was billed for $11,000 this one was billed for 800. So she's not um understanding that I explained it as simple as I could. Um she's just
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] 8240 because she maxed out. That's why it was 82, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And she's wanting to know why she only received 822.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Versus the 11,000 versus the 5000 on the other policies, but that's not what we were billed on this one.
[AGENT][NEUTRAL] Uh, let me
[AGENT][NEUTRAL] Because each bill is different and
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] It's OK.
[AGENT][NEUTRAL] Let me, let me get this, these claims pulled up and everything so that I'll be ready for her. Hold on.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I pull up that policy.
[AGENT][NEUTRAL] Now, actual charges is the, we use the um the copay, deductible and co-insurance amount to get the actual charges. So that is the, just for future reference, that's how they get uh determine the actual charge charges. We don't use the billed amount.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We use what the copay, we plug in the copay, we add the copay deductible and charged amount together, and that is the amount that we're gonna pay. So that's just a future reference for you, um, just to give you a heads up, I'm still pulling her [PII]. I'm looking at her mail, so give me just a minute.
[CUSTOMER][NEUTRAL] The actual
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Am I right?
[AGENT][NEGATIVE] Not even on the right one, hold on.
[AGENT][NEUTRAL] OK, you can go ahead and transfer her. If I have to, I can put her on hold so I can review her file further, but go ahead and transfer her, that's fine.
[CUSTOMER][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Hello, Mrs. [PII].
[CUSTOMER][POSITIVE] Yes. Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hello, Ms. [PII]. Um, give me just a few. My name is [PII]. Give me a few minutes. I want to go over your policy and look and then review your bills. So give me just a few minutes while I get that information pulled up.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And I'm gonna double check and make sure, you know, how they um what they used to pay on your claim. So give me just a few minutes.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] I apologize for the delay, but I just want to review everything.
[AGENT][POSITIVE] And then we'll go over, um, I always want to make sure everything is paid correctly.
[AGENT][POSITIVE] And I apologize for taking so long.
[AGENT][NEUTRAL] OK. So your concern regarding this call is concerning um benefits that were, you feel that your uh your claim is, your chemotherapy uh benefit is underpaid, correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, and you received um on the the other claims in the past you received more money and so you you're concerned because this was not the same amount as the the one the claims previously played, correct?
[CUSTOMER][NEUTRAL] I'm not looking for the exact same amount, but it's, no, for 80, if you look at one chemo treatment, it was way more than that. And this is two chemo treatments and it is significantly different than what I have to pay out of pocket.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Now this policy.
[CUSTOMER][POSITIVE] But you see, your son gonna even help pay the bills.
[AGENT][NEUTRAL] OK. This policy, um, only pays for the chemo drug itself. It doesn't pay any benefits for any type of, um, lab injection. OK. OK. And this policy only pays it actual charge, it only pays actual charges, which actual charges is what
[CUSTOMER][NEUTRAL] Anything different. I understand.
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] Your co-pay, your deductible and co-insurance is from your primary health insurance. So we're only gonna pay that amount of your we're only gonna pay the copay deductible and co-insurance. We add those three together, and then that is the amount that is going to be paid for that drug, chemo drug.
[AGENT][NEUTRAL] And so that is the reason why, you know, it's not they're not going by the actual charges. So for instance, on.
[AGENT][NEUTRAL] February, on [PII], your chemo drug, the total charge amount for that chemo drug is $292.85.
[AGENT][NEUTRAL] But the amount of your out of pocket expense from the um
[AGENT][NEUTRAL] After you, you're out of, after your insurance.
[AGENT][NEUTRAL] Pay their part or applied their discounts, the amount was $210.86. That was the amount that we are going to pay.
[AGENT][NEUTRAL] We're gonna pay.
[CUSTOMER][NEUTRAL] So where is all of that written at? Because I need to compare it to its conveniently I can't access the files from preview because I was gonna have that up while you talk to me, but unfortunately you got it to where it's blocked. I can't pull up that area. So I'm gonna have to go back.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You find it.
[AGENT][NEUTRAL] So you're wanting to review what bills that were sent or explanation of benefits?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Plus what you're saying, so I can see it for myself because I find it completely strange that all of a sudden, chemo treatment is $200.
[AGENT][NEUTRAL] Well, if you look at your bill.
[CUSTOMER][NEUTRAL] And my bill is way more than that.
[AGENT][NEUTRAL] Well, because your bill is including all the other besides the, the, the drug itself.
[AGENT][NEUTRAL] So, have you are you're not able to access your information at all on our website?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Nothing from last year, no.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I just tried.
[AGENT][NEUTRAL] You just tried from last year, did you, um,
[AGENT][NEUTRAL] Let me get, let me, let me find out how what we can do so that you can get access to that. So give me just one minute please. I'm gonna put you on hold.
[CUSTOMER][NEUTRAL] But I also want the information that you're telling me so that I can see it for myself.
[CUSTOMER][NEUTRAL] Because I, I want to know what you, you just, I want everything that you just told me so I know exactly what you say because when I ask these questions for specific information, I get the general manual where your limitations of pay out. I'm fully aware of that. But I want to know, I want to see exactly what you said as far as how you determine what you pay.
[AGENT][NEUTRAL] OK, so you, mhm.
[AGENT][NEUTRAL] So you're wanting to look at the bill.
[CUSTOMER][NEUTRAL] So that I know what to expect. Absolutely. I'm going to look at the bill in comparison to what you're telling me. So then moving forward, if that is your policy, then I'm aware because it seems completely different. I, I've been going through changes ever since I called the first time on this policy. It has been somebody different on this phone, telling me something different from what I've done previous years.
[AGENT][NEUTRAL] You're
[CUSTOMER][NEGATIVE] I've talked to y'all more this policy than the last two policies. And every single time I get on this phone it's something different. Just like last time I spoke to somebody about me specifically about my mammogram. She said send me the one from [PII], just send me your doctor appointment in [PII], but I only paid out for one. And and that made no sense to me because they told me that I had benefits for both years but she only gave me for one year.
[CUSTOMER][NEGATIVE] So what was my point of going through all this? So like I said, every time I've called, I get something different.
[CUSTOMER][NEGATIVE] You got to submit something different. I've never submitted this many documents. I submitted 4 freaking documents just for these two claims.
[CUSTOMER][NEGATIVE] I've never had to do that before. So it it's just too much to keep going back and forth, back and forth. And I work. I have to take care of my husband. I have to travel from here to [PII] every other week. It is too much to just have to get information and it's something different every single time I call. It is frustrating.
[CUSTOMER][NEUTRAL] And then I get the generic answers, but when I ask a specific question, you won't give me what I asked for and I'm not talking about you just in general. I'm just saying specifically. I'm asking for exactly what you said. I would prefer to have that. I would appreciate having that so that moving forward, I don't have to make many phone calls.
[CUSTOMER][NEGATIVE] It it's too much and it's frustrating.
[AGENT][NEUTRAL] So you're wanting, um, you're wanting to be able to have access to the clients that's on file for the previous years, am I correct? I'm getting that information to see how we can get that for you. If you just give me just a few more minutes while I get, you know, get that, so I'm gonna put you on hold so I can uh review that, OK?
[CUSTOMER][NEUTRAL] Oh right.
[CUSTOMER][NEUTRAL] That I think I just said that's the only thing that you got from it. That's, that is why people on the phone get upset because you guys want us to listen to what you have to say explanation, but you don't listen to the person. I know what all I asked you for. I ask you for more than that.
[CUSTOMER][NEGATIVE] But the only thing that you're gonna give me is the symbols of the, there's not in the first place.
[AGENT][NEUTRAL] So you, are you wanting copies of your entire file such as your explanation of benefits?
[AGENT][NEUTRAL] And your previous claims, is that what you're wanting?
[CUSTOMER][NEUTRAL] That is not what all I asked for. I asked for access to the previous claims and everything that you just said about co-insurance payout and what three things you ask to to make a determination. I want that as well so I know what I'm looking for and what I need to submit and what I expect to be in return. Everything that you said your determination, that should be in black and white.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, what your, what you're gonna need is, you always need the, the detailed automized bills and the explanation of benefits and in your policy certificate, it does explain that to you.
[CUSTOMER][NEGATIVE] No, it does not. Only thing that's in that policy that I have, it says what you pay for and the max. It does not say how you determine what you pay for, what information you use to make the determination. It just gives me the limitation.
[AGENT][NEUTRAL] And if you, if you.
[CUSTOMER][POSITIVE] That's all that that policy gives me. I'm ready.
[AGENT][NEUTRAL] OK, well, the part we go by what the part we adjudicate the claims by the policy.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] It's actual charges, we have to do that. Um, if you disagree with how your claim is the claims are paid, then you can appeal that and then we can put that in writing for you, but you're gonna have to send in an appeal.
[CUSTOMER][NEGATIVE] Gotta be kidding me right now. You gotta be kidding me right now.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Would you like to speak to, we have a team or a supervisor to give you a call back?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, I will, um, your telephone number is, give me one minute. I want, what's a good callback telephone number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, but you can, if you disagree with the decision of how the claims are paid, you can always, um, you can appeal that claim and put that in writing, and we can be more than happy to review that.
[AGENT][POSITIVE] But I will have the team leader to give you a call.
[CUSTOMER][NEGATIVE] Unfortunately due to the connection, I can't, I didn't hear anything you just said.
[AGENT][NEUTRAL] I apologize. Um,
[CUSTOMER][NEUTRAL] But if you have my.
[AGENT][NEUTRAL] I will have the team leader give you a call, but I also could tell you that if you disagree with any of the decisions on how the claim is paid, you can always put that in writing and send that in writing, but I will also have our team leader or supervisor give you a call, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I like to say is OK cause I can't, I don't understand anything that you can. I know it's a connection problem, so. All I heard was Tim me to give you a call, so that's fine.
[AGENT][POSITIVE] OK. OK. I will have her to call you back. Thank you. Anything else I can do for you, Ms. [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] No, that'd be all. Thank you.
[AGENT][NEUTRAL] Uh