AccountId: 011433970860
ContactId: 2c06dbbe-18fb-4d55-8769-c83af1d9eebc
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 980669 ms
Total Talk Time (AGENT): 389056 ms
Total Talk Time (CUSTOMER): 242405 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/27/2c06dbbe-18fb-4d55-8769-c83af1d9eebc_20250327T15:06_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Um, yes, ma'am. I was calling because I just wanted some clarification on um.
[CUSTOMER][NEUTRAL] A claim that I submitted yesterday.
[CUSTOMER][NEUTRAL] Um, it says that it was processed.
[CUSTOMER][NEUTRAL] And there was no payment for it, so I was just calling to see why, um, I was under the impression that that would be covered, but then I also see that.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] They filed it under a cancer policy instead of just the wellness policy, so I, I don't, I don't understand.
[AGENT][NEUTRAL] OK, I can check and you said you uh send this in yesterday?
[CUSTOMER][NEUTRAL] I did, yes, ma'am.
[AGENT][NEUTRAL] Um, OK, let me see if they just touched that claim and see what happened because yeah, it's a little bit too soon to process the claim, but I can check on it for you and see what happened. Um, may I have your name and a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, ma'am. Um, my name is [PII].
[CUSTOMER][NEUTRAL] And my phone number is [PII].
[AGENT][NEUTRAL] Thank you, Miss [PII], and may I have the policy number?
[CUSTOMER][NEUTRAL] It's 258-5.
[CUSTOMER][NEUTRAL] 345.
[CUSTOMER][NEUTRAL] Um, but that's the cancer policy. I, I guess it's, uh, I just assumed that it would be filed under the, the med link.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Policy.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] I can check on that. Um, let me have your date of birth, mailing address and email address for verification.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] My mailing address is [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] My date of birth is [PII].
[AGENT][NEUTRAL] And your email address?
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] I, I think this one's underneath my work email, which would be [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] OK. Let me go through your benefits and through your policies and see what happened to that claim, OK? Do you mind holding for me?
[CUSTOMER][POSITIVE] Oh yeah, that's fine thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding and being patient for me, Ms. [PII]. OK, so, um, I went ahead and check and see which one had the wellness benefit. It is the cancer policy. The cancer policy has the wellness benefit, um, but it looks like the test that you sent in was the CT scan. CT scan is not part of that wellness benefit. I do have a list of what we cover.
[AGENT][NEUTRAL] And um the CT scan is under medical imaging which does is if it's positive for, for cancer. If it's not positive for cancer, it's not gonna be under that and if it's gonna be under diagnostic, which is mammogram, breast ultrasounds, um, breast cancer blood tests, colon cancer blood tests, colonoscopy, virtual colonoscopy, ovarian cancer blood test, Pap smear, chest X-ray.
[AGENT][NEUTRAL] Um, then prepared, those are the ones considered under the wellness benefit.
[AGENT][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hello.
[AGENT][NEUTRAL] Miss [PII].
[AGENT][NEUTRAL] Hello, Miss [PII].
[AGENT][NEUTRAL] Miss [PII], can you hear me?
[AGENT][NEUTRAL] Hello, Miss [PII], can you hear me?
[AGENT][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] You've reached the voicemail of [PII]. I'm not able to come to the phone right now.
[AGENT][POSITIVE] Thank you for holding, Miss [PII]. Can you hear me?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK, uh, a minute ago, I don't know what happened. I was talking and I couldn't hear you, so I was trying to call you back. Um, but, um, I was, um, checking on the claim and checking on the other policies, and I see that the one that has the benefit is the one, the cancer is the one that has that wellness benefit. Now, um, you submitted a CT scan. CT scan is not uh a covered service under the diagnostic testing.
[AGENT][NEUTRAL] That is under the medical imaging test, but that is positive for cancer. Um, if it's just a wellness, um, the ones that we do consider under the wellness is the mammogram, breast ultrasound, breast mammography, breast cancer blood test, colon cancer blood test, um, we also, uh, the colonoscopy, virtual colonoscopy, ovarian cancer blood test, Pap smear, or the.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] But whenever I file a claim online,
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Um, it doesn't really get the option to, to choose which policy I'm trying to file a claim under.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Unless I'm missing
[AGENT][NEUTRAL] I'm sorry, you said unless you're missing?
[CUSTOMER][NEUTRAL] Uh, unless, I mean, OK, so when I file a claim online, it automatically goes to the cancer policy. It doesn't go towards the other.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, the other one doesn't have a wellness benefit, and that's why it goes uh directly to the cancer. The only wellness benefit you have is through the cancer policy. The Metlink, which is your secondary supplemental plan, that one doesn't pay preventatives at all.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I guess I'm a little confused because that's the whole reason I signed up for this at work.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Is
[AGENT][NEUTRAL] OK, I have a question, Ms. [PII]. Is this CT scan due to a sickness, or is this CT scan part of uh wellness like a preventative?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] No, it's, it's due to a sickness. I fainted at work on Friday. I've been having lighthead.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Um, and yeah, so.
[AGENT][POSITIVE] Got you. So apologize. Mhm.
[CUSTOMER][NEUTRAL] They told me that that should be covered under this policy. So if I'm submitting it wrong, I just need to know how to submit it, but if uh if I'm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, Ms. [PII]. It looks like you sent it to the wrong place altogether. Um, when, when you're gonna submit a claim for your secondary insurance, which is the one that helps with the deductibles, co-payment, and co-insurance, which is the mailing.
[AGENT][NEUTRAL] Um, you send it normal. Um, basically you need to get the claim form, upload the claim form and the documents that are requested with the form. Uh, the wellness claims, that's just wellness. So it's just gonna go into the policy that is for wellness and it's just gonna pay wellness. So that's the only thing that you can send in electronically is a wellness claim, but this is only for the cancer policy.
[AGENT][NEUTRAL] So in order to send a claim for your um Metin you will do upload files. That's what you need to click on upload files um you will have to go to our website and get the claim form um you can get it through, um, whenever you go in it's gonna give you an option if you need the claim form, file a form uh file a claim it's gonna take you to another page, it's gonna give you the form.
[AGENT][NEUTRAL] You're gonna fill out the claim form and then you're gonna send in the supporting documents, which is an itemized bill with the diagnosis code and also we need the explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] OK, OK, that makes sense then. I thought it should have asked for more information and it didn't, so I guess I didn't.
[AGENT][NEUTRAL] Oh, OK, yeah.
[AGENT][NEUTRAL] It's OK. I understand. Go ahead.
[CUSTOMER][NEUTRAL] And then another question
[CUSTOMER][NEUTRAL] I have 15
[CUSTOMER][NEUTRAL] I have 15 days from the date that I went to the doctor or the hospital or whatever to do this, is that right?
[AGENT][NEUTRAL] No, for claims, for your metling policy, which is your secondary, there's no timely filing limits.
[CUSTOMER][NEUTRAL] Oh, OK. So what did I read yesterday about, about the 15 days or whatever?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 15 days.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Or maybe it was 30 day. I thought it said 15.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 15 days or 30 days.
[AGENT][NEUTRAL] And that was under your mailing policy?
[CUSTOMER][NEUTRAL] Uh, I thought so, but maybe I was reading the cancer part. I don't know, but I thought, I thought something said that I had 15 days from like the date that I
[CUSTOMER][NEUTRAL] And I think it said date of loss or whatever, basically from the 15 days from the day I went to the doctor or whatever to, to get all this information and upload it to file a claim. I just don't want to miss the deadline is all.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There's not a deadline, so I'm not really sure what you were um.
[AGENT][NEUTRAL] Being, it could have been your disability or it could have been um
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] The 30 days for baby, I'm not sure. Um, but, um, yeah, there's, yeah, there's no timely filing limit, so it's OK.
[CUSTOMER][NEUTRAL] OK. Well, OK, so let me
[CUSTOMER][NEUTRAL] Uh, so if I went to the doctor in December, I should still be, I still have time to go ahead and upload for a claim from December.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, you do. Yes, you do. You have the time um since you opened the policy. So you started the policy on [PII]. So from [PII], you can still submit any claims that you have missed till today.
[CUSTOMER][NEUTRAL] Oh, OK, well then that, that answers my question.
[CUSTOMER][NEUTRAL] All right. I'll just, I'll, I'll look back at it. I thought I was, I guess I was just in a rush to try to go ahead and get it done so I didn't forget about it and everything. But if I have, if I have time to do it, then I'll just read back through it and make sure I have thing and submit it again.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, you do. You do have time to submit it. I know there's some um information that it says about the disability. I know there is like a limitation on, but it's basically on how we pay and I know there's a 30-day clause for a baby to be added to the policy or something like that. But other than that, there's really no limitations to submit claims. OK.
[CUSTOMER][NEUTRAL] OK. Well, that, that answers my question and I'll, I'll look back through it all and do it before I submit anything.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, no problem. But if you have any questions while you have it up and you're trying to like read it and stuff, um, we can see the same information you see. So you can always call us if you have any questions about what you're reading, OK?
[CUSTOMER][POSITIVE] OK, I really appreciate your help today. Thank you so much.
[AGENT][POSITIVE] You're welcome, Miss [PII]. No problem. Have a good day.
[CUSTOMER][POSITIVE] Alright you too thank you.
[AGENT][POSITIVE] Thank you. You're welcome. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Right.