AccountId: 011433970860
ContactId: 2800fbf0-3506-4557-aae5-107a7966b642
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 672090 ms
Total Talk Time (AGENT): 190633 ms
Total Talk Time (CUSTOMER): 234034 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/2800fbf0-3506-4557-aae5-107a7966b642_20250117T19:27_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good afternoon. Thanks for calling Apel. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] in customer care. How are you this afternoon?
[AGENT][NEUTRAL] I'm doing OK yourself?
[CUSTOMER][NEUTRAL] I'm doing OK myself as well. Um, I have an insured on the line. He has a cancer policy and he has a denied claim, and he needs some more information on it. I was hoping maybe you could help him with that.
[AGENT][NEUTRAL] OK, what's this callback number?
[CUSTOMER][NEUTRAL] This call back is [PII] and we're speaking with [PII].
[AGENT][NEUTRAL] What's the policy number?
[CUSTOMER][NEUTRAL] 6986664
[AGENT][NEUTRAL] Uh, uh, and the claim was for him or for his wife?
[CUSTOMER][NEUTRAL] Uh, yeah, it was for him, yeah, it was the last one reported on [PII] ending in 6029.
[AGENT][NEUTRAL] OK. OK, you can send them through.
[CUSTOMER][POSITIVE] All right, thank you so much here he comes.
[AGENT][NEUTRAL] Look.
[AGENT][NEUTRAL] Good afternoon. Thanks for calling APs [PII]. Am I speaking with Mr. [PII]?
[CUSTOMER][POSITIVE] Yes you are.
[AGENT][NEUTRAL] OK, the rep stated you had a question about the last claim that we processed, um, 354-6029.
[CUSTOMER][NEUTRAL] Right, 602 9.
[AGENT][NEUTRAL] OK, so give me one second while I pull up that claim.
[AGENT][NEUTRAL] 3
[AGENT][NEUTRAL] I'll put you on a brief hold, sir.
[CUSTOMER][NEUTRAL] What was your name again, please?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII], OK, thank you, [PII]. I'll hold.
[AGENT][POSITIVE] One sec. No problem. OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, so looking at the claim, um, the data service of 723-24 was denied because the policy doesn't cover for office visits.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] As far as the other two codes, the codes.
[AGENT][NEUTRAL] I'm pulling up the original claim to see.
[AGENT][NEUTRAL] Uh, what you were claiming for so I can give a better explanation on those.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so,
[AGENT][NEUTRAL] So the data service of 818 was denied?
[AGENT][NEUTRAL] Because that, let me see.
[AGENT][NEUTRAL] No
[AGENT][NEUTRAL] That was for a critical care evaluation, and that one is not covered on, on the cancer policy.
[CUSTOMER][NEUTRAL] What do you mean critical care, uh.
[AGENT][NEUTRAL] So, so based on the, the date of service was for [PII] and on the, the report that you sent in, there's a procedure code 99291.
[AGENT][NEUTRAL] And it says for pulmonary embolism and that's when I pull up the code, it says critical care. So it has nothing to do with cancer.
[CUSTOMER][NEGATIVE] Well, I, I have sent in y'all have requested and I talked to y'all and you told me what's needed and I got things pulmonary embolism happened uh months before my cancer.
[CUSTOMER][NEGATIVE] I had, I was in surgery for 7 hours. They pulled out a 2.5 pound tumor cancerous tumor out of my belly.
[CUSTOMER][NEUTRAL] And that's what some of the the information that I sent to you guys.
[CUSTOMER][NEUTRAL] Doctor [PII], who's on here as the
[CUSTOMER][NEUTRAL] Doctor [PII] surgery benefits 0.
[CUSTOMER][NEUTRAL] He's a surgeon. He and 4 other 3 other guys operated on me for 7 hours.
[CUSTOMER][NEGATIVE] And this is the 3rd time I've gone around with you guys and I haven't been around and around. I've asked what you need and I've tried to provide what you need. It's tough trying to get it out of the hospitals, what you actually need, they send you to somewhere else.
[CUSTOMER][NEUTRAL] Now back in [PII],
[CUSTOMER][NEUTRAL] I had an encapsulated tumor inside my left kidney.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] They took that out and y'all paid.
[CUSTOMER][NEGATIVE] What you were supposed to pay at that time now used to, I understand the pulmonary embolism not paying for that. That's not what I'm paying monthly premiums for.
[CUSTOMER][NEUTRAL] But what happens to all the information I sent you.
[CUSTOMER][NEUTRAL] About the cancer, about the 7 hours in surgery with uh a urologist, anesthesiologist, all that kind of stuff.
[AGENT][NEUTRAL] What was the data service for them because I'm just going over the the last claim that the rep had told me that you had a question about so what data service was that for?
[CUSTOMER][NEUTRAL] Well, the surgery was [PII].
[CUSTOMER][NEUTRAL] We send in information shortly after the surgery.
[CUSTOMER][NEUTRAL] And then I was, uh, I called to check on it and you said you needed more benefits, more, uh, needed something from the surgeon, so I go and get the surgeon's bill and send it to you.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] I don't know what y'all did with it, but I sent it to you.
[CUSTOMER][NEUTRAL] I mailed it.
[CUSTOMER][NEUTRAL] have
[CUSTOMER][NEGATIVE] I have a return.
[CUSTOMER][NEUTRAL] Card where y'all got it and uh.
[CUSTOMER][NEUTRAL] I'm assuming we processed it.
[AGENT][NEUTRAL] Yeah
[AGENT][NEGATIVE] So the last thing I'm looking at is showing that it was 10 pages and it has um different charges on here, um.
[CUSTOMER][NEUTRAL] This is
[CUSTOMER][NEGATIVE] I have no idea what the charges are for or whatever because I can't I don't have a thing of their codes to understand it.
[AGENT][NEUTRAL] And this is for
[AGENT][NEUTRAL] Yes, so the only thing I'm showing on this last claim that we sent, uh, hold on one sec, let me look at one other claim.
[CUSTOMER][NEUTRAL] Well, [PII] said y'all denied the whole claim.
[CUSTOMER][NEUTRAL] Is that true?
[AGENT][NEUTRAL] That's the last plan that we received, but it, that claim only had 3 different um dates on there. So I'm looking at the, the claim before that to see what was, what was on that.
[AGENT][NEUTRAL] She was just looking at the last time we processed.
[AGENT][NEGATIVE] So the last time we processed, the only dates that are on there are for [PII] and it only had one procedure code listed on here. That is the code that we denied for [PII].
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Which was for let me.
[CUSTOMER][NEUTRAL] [PII], I was in surgery for 7 hours, 4 doctors. I was in the hospital for a week, had to go back to surgery.
[CUSTOMER][NEGATIVE] The following night to replace, uh, I forgot what they replaced, something in my kidney.
[CUSTOMER][NEUTRAL] Due to the cancer.
[CUSTOMER][NEUTRAL] So I mean.
[CUSTOMER][POSITIVE] Tell me what I need to get you guys so y'all can process this for me.
[CUSTOMER][POSITIVE] We've been customers for a long time.
[AGENT][POSITIVE] Good.
[AGENT][NEUTRAL] Let me reach out to the examiner that um processed it um and let me see, ask her a question about it if you can give me just one second.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, sir. Thanks for holding. What I'm gonna do is, um, she's at lunch right now, so I'm gonna talk to her when she gets back and once I get a response back from her, I can give you a call back. Um, is your number the [PII]?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, so once I found out, I'll go ahead and um give you a call back.
[CUSTOMER][NEUTRAL] Please do because I can't tell you how outraged I am at this point, so please, please give me a call back as soon as you can.
[AGENT][NEUTRAL] Yes, sir. Yes sir, I.
[AGENT][POSITIVE] Yes, sir, I will. I'll give you a call back, Mr. [PII].
[CUSTOMER][POSITIVE] Thank you [PII].
[AGENT][POSITIVE] No problem. Have a good day.