AccountId: 011433970860
ContactId: 2b707529-5ad8-4fac-b411-546c14e4d22e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 911919 ms
Total Talk Time (AGENT): 186222 ms
Total Talk Time (CUSTOMER): 340455 ms
Interruptions: 1
Overall Sentiment: AGENT=-0.4, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/19/2b707529-5ad8-4fac-b411-546c14e4d22e_20250619T18:11_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] [PII], I'm wanting to speak with someone that can explain to me, I have a medication that I um that costs $23,000 a month and it, I called and they told me, they explained to me that the medication, they only pay $50 because it's uh uh it's a hormone, but it's being used as an immunotherapy for me and I was just trying to find out who could tell me something about that situation.
[AGENT][NEUTRAL] OK, and um who am I speaking with?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] And [PII], can I get a good call back number in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, ma'am. It's um [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And do you have your policy number with you?
[CUSTOMER][NEUTRAL] I don't have it with me this minute. No, I, let me see, I don't think I have it. I got, I can, can we find it another way because I'm not at home right now. Uh, OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, um, is it alright if I look it up by your social security number?
[CUSTOMER][NEUTRAL] Yes, ma'am. [PII].
[AGENT][NEUTRAL] OK. And what is that?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][NEUTRAL] Miss [PII], can you verify your date of birth for me, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And the address that we have on file?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, give me just a moment.
[CUSTOMER][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] OK, and I am showing, and this is just a verification of benefits, not a guarantee of payment. I am showing that radiation therapy, chemo, or immunotherapy um is covered with actual charges up to $15,000 per 12 month period.
[CUSTOMER][NEGATIVE] Well, they keep telling me that this is a hormone, although this is what I've been being treated. I've been treated with the eye brands, I've been treated with Trurop and the uh I'm taking a medication called U to do right now and it, and, and I just got the thing from the insurance and it's $23 23,000 dollars every month and I only get $50 for it and that's what I don't understand.
[AGENT][NEUTRAL] All right, let me look.
[CUSTOMER][NEGATIVE] One lady told me that she was going to go back through and look, I think her name was [PII], I'm not sure, but she told me she's gonna go back through all my claims and see what's what, but I've only the last check I got in May was $50 and it's the medication that they're, you know, trying to keep the cancer under control and I've been dealing with this now 8 years.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And uh I'm in stage 4. They found it in stage 4 and I just don't understand, you know, why I can't um I paid my policy and everything, but then they say that this medication is not covered.
[AGENT][NEUTRAL] Alright, give me just one moment, OK? Let me see if I can talk to someone about this. Give me one moment.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Referring.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], I seem to get you a lot. Um, this is [PII] over at the care team. I have a question. I have an insured on the line, policy number 727-573, and she said that she's taking a hormone, uh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] A hormone medication that's about, she said it's $23,000 a month. Um, and she's saying that she's taking it for immunotherapy for her, uh, cancer treatment, but they're only paying 75 or $50 for that, um, because it's a hormone, but she said it's for immunotherapy. She said someone from claims, and I, I checked through the notes a little bit, um, that someone is going to go back and check and see if it was still covered.
[AGENT][NEUTRAL] And I was wondering if you had, if you could um um help me figure that out on what to tell her because it's a hormone, but it's as immunotherapy. Does she need a doctor's note saying that it's for immunotherapy?
[AGENT][NEUTRAL] Because she said she's only getting $50 for it.
[AGENT][NEUTRAL] But it's for the cancer treatment.
[CUSTOMER][NEUTRAL] It would depend on
[CUSTOMER][NEUTRAL] It would depend on what her benefits are. Give me one second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] April
[CUSTOMER][NEUTRAL] from
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] And she said that someone was supposed to give her a call back.
[AGENT][NEUTRAL] Um, she said, she said someone named [PII] was going to give her a call back, um, to look into her past medical records. The only [PII] I saw cause I'm new, was a secretary, so I, I don't think it was her. The last person I saw she looked at, which I'm, these notes don't always go to the very front for me, but the last person I saw she spoke with was [PII].
[AGENT][NEUTRAL] I think is what it was.
[AGENT][NEUTRAL] Where was that?
[CUSTOMER][NEGATIVE] So it's gonna be Misty.
[AGENT][NEUTRAL] Misty, OK.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEGATIVE] I don't understand why my notes, when I first go to it, it takes me straight to [PII].
[CUSTOMER][NEUTRAL] That is
[AGENT][NEGATIVE] And it's not showing me the most up to date.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That was back in March.
[AGENT][NEUTRAL] There we go.
[CUSTOMER][NEUTRAL] Give one second I'm trying to pull up her policy.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, drugs and medicine benefit.
[CUSTOMER][NEUTRAL] Uh, outpatient $50 per prescription up to $100 per month. One second.
[CUSTOMER][NEUTRAL] OK, so it, you know, therapy.
[CUSTOMER][NEUTRAL] Uh, da da da.
[CUSTOMER][NEUTRAL] So you know therapy benefit we'll pay the actual charges up to 15,000 for 12 month period. So it looks like the information she sent in last time. So is she, is she questioning what we paid the recent payment that we made, do you know?
[AGENT][NEUTRAL] Um, she's wondering why she, yeah, she's wondering why she's only getting that hormone therapy benefit of $50.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And why it's not going towards her immunotherapy benefit.
[CUSTOMER][NEUTRAL] OK. Uh, for hormone therapy.
[AGENT][NEUTRAL] When she's taking it for immunotherapy.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, for the hormone therapy, it only pays up to $50 per treatment up to $12 per calendar year.
[AGENT][NEUTRAL] OK. Yeah, and that's, and that's what I told her, but then she said she's taking it as an immunotherapy. And I, I didn't, I'm not versed well enough in this to know if
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] She would need like a doctor's note saying that it's for immunotherapy and not necessarily hormone therapy. Um.
[CUSTOMER][NEUTRAL] Uh, if it is immunotherapy, then we would need the, uh,
[CUSTOMER][NEUTRAL] She's probably sending the explanation of benefits because we pay the actual charges, so we would need the explanation of benefits.
[CUSTOMER][NEUTRAL] So that we could see uh what the actual charges are but if you wanna send her over I can speak with her.
[AGENT][POSITIVE] OK, thank you so much.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hi [PII], I have [PII] from claims and she's gonna help uh help guide you through that, OK?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Hi, good afternoon, this is [PII] how are you?
[CUSTOMER][POSITIVE] I'm all right. How are you doing? I'm doing well, thanks for asking.
[CUSTOMER][NEUTRAL] OK. Uh, Ms. [PII], she said that you were stating that you had immunotherapy performed. Is that correct?
[CUSTOMER][NEGATIVE] Yes, ma'am, the uh medication that they're giving me, uh, they said it was being used. It's called Orcido, the new one I took uh I took uh Ibras for almost 6 years and it stopped working and they started me on.
[CUSTOMER][NEGATIVE] One called True Cap, and it gave me a reaction. And so I got started on the Ordo and I send the claims in, but only, they only pay $50 every time and I, and the medication costs $23,000 a month.
[CUSTOMER][NEUTRAL] OK. And if it's the hormone being, then why is it so high?
[CUSTOMER][NEUTRAL] Uh, I don't know, uh, so I'm thinking that they must have looked this information up. Let me see if I have there's any notes in here. Yes ma'am.
[CUSTOMER][NEUTRAL] And so I'm sure they looked it up to see what it was.
[CUSTOMER][NEGATIVE] Mm someone named [PII] I talked to, I think that was her name, and she told me she was gonna go back through the claims and check it out and see what was what, but I never heard anything and then I just need to find out, you know, why is it costing so much if it's not what, you know, what I'm supposed to be uh getting in uh.
[CUSTOMER][NEUTRAL] Um, I've, I've, I've been taking it for ever since probably February or sometime, and when I send my claim in, every time I send it in, it says immunotherapy or it says on this thing I have it says immuno immunotherapy or or uh chemo radiation 0.
[CUSTOMER][NEUTRAL] And that's what's been on all of them, but it paid $50 on it, uh, for the last 2 or 3 months, I think it only paid $50 on it, but yes ma'am all the that's that's the maximum.
[CUSTOMER][NEUTRAL] OK, cause the max benefit for for hormone drugs is $50 per treatment. Mhm.
[CUSTOMER][NEUTRAL] Mhm. So why are they, uh, charging so much? That's what I'm trying to find out if it's just a hormone.
[CUSTOMER][NEUTRAL] That I would not know Ms. [PII]. I'm sorry, um, you would.