AccountId: 011433970860
ContactId: 349a4596-e643-435c-a107-a87a06a45113
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 703109 ms
Total Talk Time (AGENT): 309070 ms
Total Talk Time (CUSTOMER): 293112 ms
Interruptions: 3
Overall Sentiment: AGENT=1.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/18/349a4596-e643-435c-a107-a87a06a45113_20250218T19:32_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. Policy number 2579522.
[CUSTOMER][NEUTRAL] And claim number or OSC 92726.
[AGENT][NEUTRAL] OK, and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Uh, right now it would be [PII].
[AGENT][NEUTRAL] Thank you for that. And I have your policy here. I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the email address.
[CUSTOMER][NEUTRAL] Uh, I don't know. It could be my work, which would [PII] [PII].
[AGENT][POSITIVE] Oh, I see. Yes, that's correct.
[CUSTOMER][NEUTRAL] Or it can be OK, right.
[AGENT][NEUTRAL] And thank you for verifying and then you were wanting to know the claim status?
[CUSTOMER][NEGATIVE] Well, I got a I've got a text that it was closed, it was that it was completed, but I went online and it's showing that they're not gonna pay anything and I'm curious as to why.
[AGENT][NEUTRAL] OK, let's see. Hold on one second.
[CUSTOMER][NEUTRAL] Because my charges say uh.
[CUSTOMER][NEUTRAL] Chemo hormone, anti something.
[CUSTOMER][NEUTRAL] Of $290 and the the medicine itself is full vestrate.
[CUSTOMER][NEUTRAL] And that's almost $5000 and I've turned in these for dates of service 13-25.
[CUSTOMER][NEUTRAL] And 1 [PII].
[CUSTOMER][NEUTRAL] Which are identical. I have to do this once every 4. I have to do this every 4 weeks.
[AGENT][NEUTRAL] OK, hold on one moment, let me see what's going on.
[CUSTOMER][NEGATIVE] For my cancer.
[AGENT][NEUTRAL] Well, just for the call, the information provided is a verification of benefits, not a guarantee of payment. So I do see that the claim was denied, um, looks like it was denied because the maximum, the policy maximum for chemo or radiation therapy for this benefit period has been met. Let me see what the benefit is.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Well, the benefit period was 1124 to 123124.
[CUSTOMER][NEUTRAL] 1125 started a new benefit period.
[AGENT][NEUTRAL] Right, but even so, this is the first claim, so.
[CUSTOMER][NEUTRAL] Yes ma'am, that's the first claim for [PII].
[CUSTOMER][NEUTRAL] Because I was told to go ahead and turn it in, um.
[CUSTOMER][NEUTRAL] Because it started a new.
[AGENT][NEUTRAL] Calendar year.
[CUSTOMER][NEUTRAL] A new policy period, yes ma'am, but if it's reverting back to
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Treatment
[CUSTOMER][NEUTRAL] Then I'll have to
[CUSTOMER][NEUTRAL] Sub start submitting them.
[AGENT][NEUTRAL] Hold on, hold on, hold on one second. That's just one of the reasons. There is, hold on one moment. Let me look at this claim [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so that denial code was for, so there's 24 different codes on this um claim.
[AGENT][NEUTRAL] So, the first one.
[AGENT][NEUTRAL] Um, for procedure code J like juice 9395, that's the one that was denied because the chemo or radiation therapy had been maxed for the benefit period. The next one.
[AGENT][NEUTRAL] was for radiation delivery, but we don't, um, the policy doesn't cover like
[CUSTOMER][NEUTRAL] I didn't get any I didn't get any radiation.
[CUSTOMER][NEUTRAL] Well, the radiation is part of my cupboard.
[CUSTOMER][NEUTRAL] Plan benefit.
[AGENT][NEUTRAL] So when I was um
[CUSTOMER][NEUTRAL] But I haven't
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEGATIVE] I haven't received any radiation.
[CUSTOMER][NEUTRAL] I haven't had radiation since [PII].
[CUSTOMER][NEUTRAL] 15
[AGENT][NEUTRAL] So the
[AGENT][NEUTRAL] So this, I was just reading you the, the, um, denial reason. So radiation was a part of it. It was radiation, chemo or immunotherapy benefit. Um, so, so I'm just gonna go back a little bit. So I was just going to let you know if that one code was denied because it was delivery, for it could have been for radiation, chemo, or immuno, it covers all three, but it's
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] We only covered the administering of it, not the delivery of it. So that's why this is our testing, that's why this
[CUSTOMER][NEUTRAL] OK, what do you mean? What's the difference between.
[CUSTOMER][NEUTRAL] Delivery and the other words you said.
[AGENT][POSITIVE] Delivery and administering. Delivery is how it's received, how it's how it's being brought to the location.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Like if you were to buy it and.
[AGENT][NEUTRAL] Um, what is it called?
[CUSTOMER][NEUTRAL] Oh no, all this is done right there at Texas Oncology, so.
[AGENT][NEUTRAL] So did you want me to like read the, the denial reason to you in it in its entirety?
[CUSTOMER][NEUTRAL] Well, will I be getting that in the mail?
[AGENT][NEUTRAL] Let me see. Yes, ma'am.
[CUSTOMER][NEGATIVE] Because I hate for you to spend all the time reading that to me because I will have more questions.
[CUSTOMER][NEUTRAL] Because my first question is that denial said it was.
[CUSTOMER][NEUTRAL] The maximum had been met.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Per 12 month period. Well, I'm beginning a new 12 month period.
[CUSTOMER][NEUTRAL] So do they go by policy period or do they go by 12 month period?
[CUSTOMER][NEUTRAL] From the
[CUSTOMER][NEUTRAL] Date of your treatment last in [PII].
[AGENT][NEUTRAL] Well, that's what I was saying. Regardless, this is the first claim that we process on this policy for you, not ever on this.
[CUSTOMER][NEUTRAL] Right, for [PII]. Uh-huh.
[AGENT][NEUTRAL] No, no, so.
[AGENT][NEUTRAL] So you had a previous, um, OK, so basically we, you had your your policy ported. So you had a policy that was active from [PII] 2024 to January 1st of 2025. [PII].
[CUSTOMER][NEUTRAL] Well, actually it was a full 12 months.
[AGENT][NEUTRAL] So I'm not, I'm
[CUSTOMER][NEUTRAL] I don't know why had to be something with y'all system because.
[CUSTOMER][NEUTRAL] The policy was I've continually had a policy with y'all now for like 6 or 7 years.
[AGENT][NEUTRAL] Right, I'm just trying to explain to you the difference so that you know why it's, so that you know why it's um saying for
[CUSTOMER][POSITIVE] Oh, I'm sorry.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For the calendar year. What I'm saying, I'm, I'm saying the same thing you're saying I actually think this needs to go back to be reprocessed, but what I'm trying to explain to you is this is the first claim that we've processed under this policy number. You've had policies with us since, so whether it's the that denial reason doesn't make sense because it's the first claim ever on this policy.
[CUSTOMER][POSITIVE] Yes ma'am, that is correct.
[CUSTOMER][NEUTRAL] Yeah, OK, I'll follow you.
[AGENT][NEUTRAL] So that's how I was trying to say. I think that for that part, it does need to be looked at again. The other um
[AGENT][NEUTRAL] The other codes, one was because office visits aren't covered.
[CUSTOMER][NEGATIVE] Right, and I didn't ask for, you know, the office visit to be covered that's I knew that, but it is on the bill because they can't split they can't split my bill up and only show.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] My treatment.
[CUSTOMER][NEUTRAL] Everything's on there like my office visit was $310. Well, I know that's not covered, but of course on y'all side y'all have to address it.
[AGENT][NEUTRAL] Because it's on, right, mhm.
[CUSTOMER][NEUTRAL] Yeah, but I had highlighted the and I don't know if it came over highlighted. I highlighted the the uh treatment part.
[CUSTOMER][NEUTRAL] But they must be looking at the whole thing.
[AGENT][NEUTRAL] Yes, ma'am, and then the last one was for labs, um, and laboratory tests are not a covered benefit on the policy.
[CUSTOMER][POSITIVE] That's correct. I'm in agreement.
[AGENT][NEUTRAL] So I can um for the other two, I can definitely go ahead and send this back to be reprocessed or um
[AGENT][NEUTRAL] I can have for a claims examiner to give you a call back. They usually call within 24 hours to go over with you if there is an explanation.
[CUSTOMER][NEUTRAL] Well, if you'll send it back and have them review it since like you mentioned it is the first claim on this policy.
[CUSTOMER][NEUTRAL] Um, and I, I know my maximum.
[CUSTOMER][NEUTRAL] It's 20 I do know that that's 20,000 so um.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, these two, these two.
[CUSTOMER][NEUTRAL] But you know, be like almost half of that, so I would only turn in like 2 more.
[AGENT][NEUTRAL] OK, well, I can definitely send this back to be reprocessed for you. Um, so,
[CUSTOMER][POSITIVE] I would appreciate that.
[AGENT][NEUTRAL] Oh, you're very welcome. So when it's reprocessed, um, we usually say to give it still that 7 to 15 business days. It could be less time than that. That's just the typical turnaround for the claims.
[CUSTOMER][POSITIVE] No problem.
[AGENT][POSITIVE] Alrighty.
[CUSTOMER][POSITIVE] No problem at all. Thank you so much for taking my call and I apologize for being confused at first.
[AGENT][POSITIVE] Oh, there's no reason for apology. That's what we're here for. Was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's it.
[AGENT][POSITIVE] Alrighty well thank you so much.
[CUSTOMER][NEUTRAL] Yeah, they'll just review those uh.
[CUSTOMER][NEUTRAL] 2 $290 charges and the 2.
[CUSTOMER][NEUTRAL] 4880 charges because that's the that's the actual treatment there.
[AGENT][NEUTRAL] OK, but you mean all of them on this because I'm sending this whole claim over. You mean, you mean everything on this claim, right? Except for the office visit?
[CUSTOMER][NEGATIVE] No office visit, no lab because I don't, I know they don't pay for that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It would be the codes 96402.
[CUSTOMER][NEUTRAL] And J 9395. Yes, ma'am.
[AGENT][NEUTRAL] J 930.
[AGENT][NEUTRAL] Yes, these. OK. Well, I'm sending this over now. I'm putting the request in um for you now.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] You're very welcome. Well, thank you so much for calling APL and I hope you have a good evening.
[CUSTOMER][POSITIVE] You as well thank you alrighty bye bye.
[AGENT][POSITIVE] Thank you. You're welcome. Bye-bye.