AccountId: 011433970860
ContactId: 2b94162c-5c4c-44d2-83eb-9ca6824151ec
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 569799 ms
Total Talk Time (AGENT): 301197 ms
Total Talk Time (CUSTOMER): 141043 ms
Interruptions: 0
Overall Sentiment: AGENT=1.5, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/13/2b94162c-5c4c-44d2-83eb-9ca6824151ec_20250113T17:58_UTC.wav
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[AGENT][POSITIVE] Hi, thank you for calling ATL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Ma'am, I need to see if the hormone medicine I'm taking is covered under my policy.
[AGENT][POSITIVE] OK, yeah, I can do my best to help you out with that today. Can I have your name and your policy number?
[CUSTOMER][NEUTRAL] Uh, [PII], I don't know the policy in my opinion, ma'am.
[AGENT][NEUTRAL] No, that's OK. Um, I can search it with your social if you'd like me to.
[CUSTOMER][NEUTRAL] OK, [PII].
[AGENT][NEUTRAL] And I'm so sorry, you said [PII] at the start?
[CUSTOMER][NEUTRAL] No, no, [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you so much. Give me 1 2nd to get that looked up for you, my friend.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And Mr. [PII], could you verify for me, please, your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And I do just need to verify a couple of pieces of information if you don't mind verifying with me your mailing address on file.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. And then the email and phone number.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] Perfect, and is that a good number to call you back if we were to get disconnected?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. And let's see.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] And we're wanting to look under your cancer policy, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] So I'm just gonna pull up that like policy certificate that kind of goes over um all of your policy details and I'm just waiting for that to load.
[CUSTOMER][NEUTRAL] Yeah, when I pull up the pocket, I didn't see a list of medicine that was covered, but yeah, go ahead.
[AGENT][NEUTRAL] Yeah and I'm not sure yeah I'm not sure if.
[AGENT][NEUTRAL] It has like a list or but we're gonna just take a look at it. Let's look at benefits in section 5.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So as long as my doctor, he's a regular doctor, he put me on it, so it should be covered.
[AGENT][NEUTRAL] And you said it was, what type of medicine?
[CUSTOMER][NEUTRAL] Um, hormone therapy.
[AGENT][POSITIVE] OK, perfect. You do have a benefit for hormone therapy, and I'm just gonna read it to you. Um, it says we will pay the indemnity amount shown in the schedule of benefits per calendar year when a covered person receives hormone therapy treatment prescribed by a physician.
[AGENT][NEUTRAL] This benefit payable per treatment subject to the maximum number of treatments shown on the scheduled benefits. This benefit covers the drug and medicines only. It does not include associated administration process. This benefit does not include any anti-nausea or pain medicine or administration thereof of any drug or medicines covered under the radiation therapy, chemotherapy, or immunotherapy benefit.
[AGENT][NEUTRAL] And then with that being said, let me look at what that schedule of benefits says for you um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh maybe it's at the bottom. I went up hold on one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and I do wanna let you know any benefit information, I'm sorry, I should have led with this, but any benefit information I give you over the phone, um, it's just a verification of coverage, but never a guarantee of payment.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it says for hormone therapy under your schedule of benefits, it says per treatment up to a maximum of 12 treatments per covered person per calendar year is a $50 benefit.
[CUSTOMER][NEUTRAL] A $50 total?
[AGENT][NEUTRAL] $50.
[CUSTOMER][NEUTRAL] Or $50 per.
[AGENT][NEUTRAL] Per visit up to 12 visits a year.
[CUSTOMER][NEUTRAL] OK, what do you mean by visits? I mean, they give me like a medicine. It's like a monthly medicine I take for hormone treatment.
[AGENT][NEUTRAL] Oh, it covers you up to 12 treatments per year, so that's about once a month as it dices out.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it covers, it says per treatment, so it's 12 treatments per year, which if you're taking it once a month would cover the every month and then it's a $50 benefit per treatment.
[CUSTOMER][NEUTRAL] OK, so it doesn't matter how much I pay for the medicine, it's just $50 per treatment.
[AGENT][POSITIVE] Yeah, because it's um it's like an indemnity amount so it's gonna be a fixed rate um every time.
[CUSTOMER][NEUTRAL] OK. So do it matter which medicine I'm taking as long as it's prescribed by my doctor and it's for hormone therapy?
[AGENT][NEUTRAL] It does say as long as it's not covered under the radiation, chemo, or immunotherapy, so as long as it's also not considered one of those, um, but it doesn't look like it's explicit to any particular medicine.
[AGENT][NEUTRAL] From what I can see.
[CUSTOMER][NEUTRAL] OK, how would I file a claim?
[AGENT][POSITIVE] Oh that's a wonderful question so we have our cancer claim forms um they're available online, but I can also email one out to you um to that email address you just gave off to me on file and.
[AGENT][NEUTRAL] And let me pull up the claim form. I don't wanna give you any of the wrong information.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, cause I already made the claim form. I just need the, the one for that medicine. I always have different claims for different forms. I just need it for to get my hormone therapy.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] You bet you, so that one you're just gonna submit your itemized bill from your medical provider and your explanation of benefits.
[CUSTOMER][NEGATIVE] OK, they don't give me automatic bills for prescriptions for them for the hormone prescription.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] They just give me a medicine.
[AGENT][NEUTRAL] Do you have a like an itemized like are you picking it up at the pharmacy?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so your itemized bill can be from the pharmacy I believe.
[AGENT][NEUTRAL] Let me, you know what, let me double check that though. Do you mind if I put you on a quick hold and I just double check that information?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEGATIVE] Yeah, because I'm, I'm, I'm getting tired of sending stuff in they get declined, you know, it just drives me crazy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yeah, let me check on that for you, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Transferring.
[AGENT][NEUTRAL] Mhm mhm mhm.
[CUSTOMER][POSITIVE] Good afternoon. Thanks for calling April. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey this is [PII] with the care team. How you doing today?
[CUSTOMER][NEUTRAL] I'm doing OK, and yourself?
[AGENT][POSITIVE] Hey, I'm doing wonderful. Um, I just had a gentleman on the line with a question about like what information he needs to submit um for his cancer hormone therapy treatment.
[CUSTOMER][NEUTRAL] OK, um, what's his callback number?
[AGENT][NEUTRAL] Um, yes, his callback number is [PII].
[CUSTOMER][NEUTRAL] His policy number?
[AGENT][NEUTRAL] Uh, his policy number, I'm so sorry. Let me go back. I'm in the claim response, um.
[AGENT][POSITIVE] I'm so sorry.
[AGENT][NEUTRAL] I should have been ready. It is 252-856-1.
[CUSTOMER][NEUTRAL] For uh [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, you can go ahead and send them through.
[AGENT][NEUTRAL] OK perfect he just has a question I think more concerning the itemized billing um if it's able to come from his pharmacy, but I will introduce you and you said your name was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK perfect I'll introduce you when we join, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Hi [PII], are you still there?
[CUSTOMER][NEUTRAL] Yes, I'm still here.
[AGENT][POSITIVE] Hey, I really appreciate your patience. So I actually have a Ms. [PII] on the line and she is going to take the call over. She does um handle those cancer policy and claims, and so she's going to be able to provide you with a little more detailed information on what we would need from you, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Perfect, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hi, Mr. [PII], this is [PII] in the claims department. Um, the rep stated you had a question about um what you would need to send in for your, um, for a claim. Hormone. Yeah, for hormone therapy, yes.
[CUSTOMER][NEUTRAL] The hormone therapy is just appeal.
[CUSTOMER][NEUTRAL] OK, so, um, let me see, hold on one second. Uh.
[CUSTOMER][NEUTRAL] Give me 1 2nd, I'm sorry.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Do you know the um name of the hormone pill that you're taking, are gonna be taking?
[CUSTOMER][NEUTRAL] Yes, hold on one second, let me get you divorced so I.