AccountId: 011433970860
ContactId: 299f9971-12b7-4739-af82-407b210e128b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 587210 ms
Total Talk Time (AGENT): 373742 ms
Total Talk Time (CUSTOMER): 163337 ms
Interruptions: 2
Overall Sentiment: AGENT=1.1, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/24/299f9971-12b7-4739-af82-407b210e128b_20250424T14:16_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][POSITIVE] Hey [PII], it's [PII] on the care team. How's it going today?
[AGENT][POSITIVE] It's going pretty good. How are you, [PII]?
[CUSTOMER][NEUTRAL] So far so good, thanks. So I've got a provider on the line, uh, he's calling about a, uh, cancer patient, um, and their cancer policy. Um, I can give you that policy number. In short, he has, um, skin cancer, which I don't see as an exclusion on this one, and he's having a surgery to remove a malignant lesion and a tissue transfer.
[CUSTOMER][NEUTRAL] I see the surgical benefit writer, but I don't see anything specific regarding that, so I wasn't sure what to tell her.
[AGENT][NEUTRAL] So she's needing to know like what needs to be submitted?
[CUSTOMER][NEUTRAL] No, um, just if that would be, um, a benefit, uh, payable benefit under this policy.
[AGENT][NEUTRAL] Oh, got you, got you, OK, yeah, what's that policy number?
[CUSTOMER][NEUTRAL] It's 253-233-0.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] Excuse me.
[CUSTOMER][NEUTRAL] Like usually I feel like under the
[CUSTOMER][NEUTRAL] The surgical benefit writers, that would kind of give more specifics, but I don't see that.
[AGENT][NEUTRAL] So under the surgical benefit rider, um, it is based off of the code that they use, um, that is how we pay, so.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The list, if there is one, isn't going to necessarily um provide all of the benefits that we.
[AGENT][NEUTRAL] Would pay, it's just going to kind of mention like sometimes you know it has like different surgeries that are coverable and how it's covered um for this one specifically.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It just says um that we provide.
[AGENT][NEUTRAL] That the benefits we provide for this loss are incurred while the covered person is under this router following a diagnosis of cancer or skin cancer and for treatment of cancer or skin cancer. And it just says a charge must be incurred. So the way that it's determined is based off of the code.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so in short it would most likely be covered, but you know I'll just give disclaimer and that's pretty much that.
[AGENT][NEUTRAL] Yeah, um.
[AGENT][NEUTRAL] You don't have to go into it but just kind of this information for you so when it says unit dollar amount is $30 so we go by relative value which is a screen that we look at to look up the CPT codes and that's kind of the units that we're looking at so you know if they were to have um.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] A surgery like that has 17 units, then what the system does is it takes that those units and multiplies it by their dollar amount to determine the payable amount.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][MIXED] Interesting, OK, but it's, uh, it wouldn't exceed that 3000.
[AGENT][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] Right, it's, it's not going to exceed the 3000 and if there's more than one on um on a day or through, I think it's through the same procedure, let's see, um, let's see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, we will pay the lesser if that's not it. OK, 2 or more surgical procedures performed through the same incision. So they're considered one operation. So when they take the tissue from the other location.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That may be considered because it's like if they were to take it from their stomach or their thigh or their back, which are pretty common areas because of how much surface area there is. And let's, right, that is probably something that we would cover because let's say they're putting it on their face or their hand or something like that. It's a different incision. So they're removing it here and they're replacing it here, but the removal of the
[CUSTOMER][NEUTRAL] Yeah, the excess, mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Malignant cancer and then the tissue on top would likely just be considered one because it's all one area. So that's the only difference there. It's possible that not every procedure this day will be covered, but
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, we will consider it because skin cancer treatment, surgical procedures are covered under this benefit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] That's interesting. I swear I love talking to you. You just always, it's so informative. Um, really, I'm so, you're so good. Um, well, if you wouldn't mind, could you explain that to her?
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Oh, I love it.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I really appreciate it. I just don't wanna I feel like I understand, but I don't wanna say something wrong um her name is uh [PII].
[AGENT][POSITIVE] No problem.
[AGENT][POSITIVE] [PII], OK, yeah, I'll be happy to.
[CUSTOMER][NEUTRAL] Yes, and this is for uh part two is for [PII].
[AGENT][NEUTRAL] Part two, OK.
[AGENT][POSITIVE] Perfect.
[CUSTOMER][POSITIVE] Yes, I appreciate your help. Thank you so much, [PII].
[AGENT][POSITIVE] No problem. You're welcome, [PII].
[CUSTOMER][NEUTRAL] All right, bye.
[AGENT][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Ms. [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hey, this is [PII] with the clients department how are you?
[CUSTOMER][POSITIVE] Hi, I'm doing good, thank you. How about yourself?
[AGENT][NEUTRAL] I'm doing well. Um, so [PII] was saying that you just had questions on whether, um, some surgical procedures for one of our insured would be covered. Is that correct?
[CUSTOMER][NEUTRAL] Um, yeah, so I am checking what benefits are available for this type of coverage for, yes, the patient who's scheduled to have surgery.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So they do have a surgical procedure benefit um the payable amount is based off of the relative value of the procedure code or procedure codes if they have more than one, so there's not really like a, a dollar amount I can give you like, oh we pay this much for this type of surgery, um.
[AGENT][NEUTRAL] But it will, the benefit does not exceed $3000 per operation for this particular policy. Um, additionally, if two or more surgical procedures are performed through like the same incision, um, then those are considered one operation and we only will pay the most expensive.
[AGENT][NEUTRAL] Um, and then, you know, on the flip side if they're performed through different incisions they're considered two operations and we would pay for each. So, um, neither of the operations would exceed that $3000 limit per operation and um.
[AGENT][NEUTRAL] And it does include skin cancer treatment. So it does stay in the policy, um, that it's for, if it's for a covered diagnosed cancer, skin cancer, or for reconstructive surgery due to cancer.
[AGENT][NEUTRAL] Then we'll consider benefits under their surgical benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Well, that, I understand what you've said. It looks, it looks like they were looking for more. No.
[AGENT][NEUTRAL] OK, OK, I was like, uh, do you have any more questions?
[CUSTOMER][NEUTRAL] Yeah, they're kind of looking for a set policy that would give like a certain dollar or percentage on what they would cover for um for this treatment, but I see that you're saying it just varies. Uh, it's based off of um I guess reasonable, maybe reasonable customary or like uh um.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Well, it's based off the relative value of the procedure. So like if they, so, um, you know, like if they, and we pay $30 per unit. So like if they were to have a surgery and when we look in our system, it's set up as having a relative value of 5.
[CUSTOMER][POSITIVE] Relative value. OK.
[AGENT][NEUTRAL] Then it would be what our system does is it takes that unit dollar amount and multiplies it by the relative value to give us a surgical procedure amount so it's going to vary based off of the surgery, which is why there's not a set amount um it's not like, oh well we pay $500 for this or $1000 for that or you know it's not like that at all it's, it's strictly based off of the type of procedure that's performed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] All right, well, I will, um.
[CUSTOMER][NEUTRAL] Put this, uh, give this information back to who is requesting it and if there's any more questions, we'll reach back out, but I think that, um, pretty much covers it then. Thank you.
[AGENT][POSITIVE] OK. You're very welcome. Have a great day, [PII].
[CUSTOMER][POSITIVE] Thanks you too. Bye.
[AGENT][POSITIVE] Thank you. Bye-bye.