AccountId: 011433970860
ContactId: 1df5d4ca-ca4c-41f9-a809-7a7f5c1062b4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 897309 ms
Total Talk Time (AGENT): 170000 ms
Total Talk Time (CUSTOMER): 491780 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/03/1df5d4ca-ca4c-41f9-a809-7a7f5c1062b4_20250403T20:16_UTC.wav
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[CUSTOMER][NEUTRAL] Hello.
[AGENT][POSITIVE] Good afternoon. Thanks for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], it's [PII] on the care team. How are you?
[AGENT][POSITIVE] I'm good. How are you?
[CUSTOMER][NEUTRAL] I'm doing good um I have an insured on the other line that needs to speak to you. Um, we're going over a claim you, you want me to give you the policy or the claim number?
[AGENT][NEUTRAL] Uh, you can give me the policy.
[CUSTOMER][POSITIVE] Wow
[CUSTOMER][NEUTRAL] OK. It's 87821.
[AGENT][NEUTRAL] She wants to speak to me or she just want to speak to somebody about the claim?
[CUSTOMER][NEUTRAL] Just somebody, just the claims.
[AGENT][NEUTRAL] Alright, because I was just gonna say I have no idea alright.
[AGENT][NEUTRAL] And part one, part two?
[CUSTOMER][NEUTRAL] It's part one.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And the claim number?
[CUSTOMER][NEUTRAL] OK. And it's the first claim there, uh, well, last claim, 3582151?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we went over the claim, went over the explanation of benefits. So it sounds like he sent, he said he sent in something with 50 something pages. I don't see it. But I told him he can use, he's trying to match the information on the explanation of benefits to what he sent in. He said he numbered the pages.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I looked at the documents that were received, but all I saw was the claim form. So I told him to look at the explanation of benefits, the date of service, and match it to whatever dates of service on the documents he sent in. And then I told him to look at the remarks, and then on page 2, it'll it'll tell the description of those numbers.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So he now
[CUSTOMER][NEUTRAL] He now wants me to find these 52 pages and
[CUSTOMER][NEUTRAL] Like for, like for this, for example, [PII], that first line there, benefit name not found. I told them it was an office visit.
[CUSTOMER][NEUTRAL] Um, he wants me to, he's like trying to get me to match the explanation of benefits to what was sent in, but I don't see anything other than the claim form.
[AGENT][NEUTRAL] OK, for some reason, for some reason her claim numbers are not, um, this one actually has 61 pages.
[CUSTOMER][NEUTRAL] Like, you know how
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] So if it's not there I know y'all y'all not supposed to do this but if isn't you don't, when you click on it and try to put a claim number up if it's not there you can also search by that mail number.
[AGENT][NEUTRAL] Oh shoot, come on, because I'm gonna attach the claim number to it and see.
[AGENT][POSITIVE] Alrighty you can send him on over.
[CUSTOMER][NEUTRAL] OK, thank you, [PII], hold on one second.
[AGENT][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] Hello, Mr. [PII]? Yes, ma'am.
[CUSTOMER][POSITIVE] Thanks so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][POSITIVE] Good afternoon. Thanks for calling APO. This is [PII], and how can I help you?
[CUSTOMER][NEUTRAL] Yes ma'am. This is [PII].
[CUSTOMER][NEUTRAL] I submitted a claim.
[CUSTOMER][NEUTRAL] For I have prostate cancer and I have, I've not started any treatments, but I have a whole bunch of stuff from when I got to my doctor and I did a biopsy, I did an MRI, all things that they want it done for diagnosed some way and whatever.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I have all that here, and I submitted it, and when I did, I numbered the pages so that when I call you and I got the EOB here and I'm going, OK, it says benefit name not found. Hm, I had no idea what that means. If you can look on your claim that I, my forms that I sent.
[CUSTOMER][NEUTRAL] And see what you determine where that's from so I can look and see, OK, well that I don't want to be replicating this later on if I get to a point where I do have to submit.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] Uh, things for, uh, treatment. And if you're not gonna need it, I don't always say it to you, yeah, this is what I'm trying to get to a point here. Just tell me what I need, what I have here is not relevant and I won't be sending it to you again.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The first thing is they have on here is uh [PII] benefit name not found. OK.
[AGENT][NEUTRAL] OK, so those were.
[CUSTOMER][NEUTRAL] And where did that come from?
[AGENT][NEUTRAL] Those were office visits.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Office visits. OK, let me ask you this. When
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] You, when someone looked at my paperwork.
[CUSTOMER][NEUTRAL] To see that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What page number that I when I submitted.
[CUSTOMER][NEUTRAL] So that's all that period, no office visit. 00, so it be multiple pace, hold on.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][POSITIVE] OK office business.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So you got, I sent you something.
[CUSTOMER][NEUTRAL] With an office visit on.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, hold on a second. Let me, let me start out with a fresh piece of paper here because I don't want to get myself hold on.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm sorry I'm not the payer.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] So benefit name I found equals offices.
[AGENT][POSITIVE] Mhm, that's correct.
[AGENT][NEUTRAL] Well, in this case, for those, uh those, those are office visits.
[CUSTOMER][NEUTRAL] Office, OK.
[CUSTOMER][NEUTRAL] I'm sorry to be slow about this now.
[AGENT][NEUTRAL] Oh that's fine you're fine.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] If the office visit.
[CUSTOMER][NEGATIVE] It was for me, for him to just check me up, whatever, check me. I didn't, I've already been diagnosed and all that. That's not covered.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] You're not, it's not doing anything just, OK, OK, OK, that makes sense. And in the wellness expense, I understand that that I don't know how that well I know what happened. They, um, I submitted that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Wellness expense.
[CUSTOMER][NEUTRAL] Yeah I'm not
[CUSTOMER][NEUTRAL] Yeah, I, I remember when I submitted that, uh, first claim.
[CUSTOMER][NEUTRAL] Not first claim, but the, the, the, the actual, OK. The actual uh diagnosis and uh they sent a check for $1000. I was saying, yeah, you have cancer, OK, $1000 and then $75 for the office visit. So that's what that is. OK, the first two.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The the the number 2 on there, OK, OK, and I, I was looking at the back and it says calendar year maximum, yes, OK, OK, I can, I can understand that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I'm, I'm, I don't know where to get transportation for automobile. I didn't send anything in unless it was picked up some kind of way. Yeah, I'm not that part of Baton Rouge. OK. The next one is, uh, let's see, number 4 is policy provider, provides no benefits for a biopsy.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So when he did the biopsy, why is that not covered? I mean, what's the deal? It's not for the treatment or what?
[CUSTOMER][NEUTRAL] Because I did a biopsy. They want to see where the cancer was on my prostate, and they did a biopsy and got like 1718 different spots on there.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But that's not covered under the policy.
[AGENT][NEUTRAL] Uh, it looks like it's not. Let me see if I can pull your policy up.
[AGENT][NEUTRAL] OK, it looks like the policy basically covers chemotherapy, radiation treatment. You have a daily hospital benefit and first occurrence benefit.
[AGENT][NEUTRAL] So I don't see.
[CUSTOMER][NEUTRAL] OK, and I, I probably have that somewhere, but like I said, this policy was issued in the [PII] or early [PII]. I have no idea what that would be. Can you send me something that explains what my benefits are?
[AGENT][NEUTRAL] Yes sir.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm yes sir I can send you a copy of the policy certificate.
[AGENT][NEUTRAL] Oh, let's see.
[CUSTOMER][POSITIVE] Oh great.
[CUSTOMER][NEUTRAL] That we want we're dealing with all this paperwork in you.
[AGENT][NEUTRAL] OK, alrighty and can you verify your address for me please?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Now, what's this outpatient surgery for 400?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Cause that's what I went to do the biopsy.
[AGENT][NEUTRAL] OK. Yeah.
[CUSTOMER][NEGATIVE] That's I'm confused.
[AGENT][NEUTRAL] Uh, so they probably just pay the, uh, the facility benefit. Let me go back to your benefits.
[AGENT][NEUTRAL] 1 2nd.
[AGENT][NEUTRAL] So outpatient hospital.
[CUSTOMER][NEUTRAL] Yeah, I know these pages, so if I have to talk to you, I don't know what page to go to.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] One second, I'm reviewing your schedule page.
[CUSTOMER][NEUTRAL] I worked 20 something years with the state in the insurance business, health insurance, but I was, I was not on the claims in. I didn't want nothing to do with that.
[CUSTOMER][NEUTRAL] I collected the money, I billed the premiums and that's it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] When I talked to my family, they asked me something.
[CUSTOMER][NEUTRAL] I said what's the EOB say? What's an EOB?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Explanation of benefits. I keep forgetting that, that's like combination that second language to me, some of these things and, OK, I don't know what you're talking about now.
[AGENT][POSITIVE] Of benefits, that's correct.
[AGENT][NEUTRAL] OK, it looks like that's the, the $400 that they paid. That's the max benefit they'll pay for the uh the facility charges for the hospital or the surgical center.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Even though it's for the biopsy, which they don't pay for.
[AGENT][NEUTRAL] Well, you know, whenever you have surgery, you know, you have the facility charges, you have the uh biopsy which would be the surgeon's charges.
[AGENT][NEGATIVE] So they're not paying for the biopsy, they're paying for the charges for the hospital.
[CUSTOMER][NEGATIVE] OK, so the anesthesia for a biopsy, don't pay for that. That's not covered.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK, and the, and the analysis for the lab work for the biopsy is not covered, OK? I'm I'm understanding this now, OK. So if you send me that, I appreciate that so much. It would, you know, I can have a better understanding.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh my doctors are very consoling. He says, don't, don't worry about that, that prostate cancer. You're gonna die from something else other than that.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] You're right.
[CUSTOMER][NEUTRAL] I'm going, oh gee, hold on a second, let me get this. I'm going, gee, you're, uh, you're very consul wait a while, come on, I just think, uh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And you're very consoling to tell me that.
[AGENT][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] And my pharmacist tells me the same thing. I'm looking at your chart. You have all kinds of other conditions you're di from before this. I'm on, gee, thanks.
[AGENT][NEUTRAL] Oh, right. Yeah, but so is everything going OK with your cancer?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So far, everything's fine. I, it's, you know, I'm not in any difficulty and nothing like that. And my PSA is almost at 10, but I'm hoping, I'm praying it, it stays below 10. Uh, I have a brother that's older than me that has had prostate cancer twice and licked it, and now he has bone cancer.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] And I'm, I'm following what he does and the way he does things and how he does things and so.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] That you know, I'll have an idea. I went with them yesterday to do some stuff and all that, so I won't keep you. I'm so glad I got this this clarified and if you could send me that, that benefit, I appreciate it, ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] I sure will. I'll get that done for you, Mr. [PII] and uh thank you for calling ATL. You have a great rest of your day, and I pray that your cancer is, everything goes well with you.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][POSITIVE] I, I, I accept that so much. Thank you, ma'am.
[AGENT][POSITIVE] God is good all the time.
[AGENT][POSITIVE] Have a OK thanks and have a great day.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye bye.