AccountId: 011433970860
ContactId: 3e47c163-8c2e-449d-bab5-bbcfed8aff4e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 775250 ms
Total Talk Time (AGENT): 396221 ms
Total Talk Time (CUSTOMER): 288518 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/28/3e47c163-8c2e-449d-bab5-bbcfed8aff4e_20250328T15:50_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. Uh, my name is [PII]. I was calling to check on a claim.
[CUSTOMER][NEUTRAL] Uh, for my wife.
[AGENT][NEUTRAL] It.
[AGENT][NEUTRAL] OK, yeah, I could check on that claim for you. uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Uh yeah, [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, do you have that policy number?
[CUSTOMER][NEUTRAL] Yes, it is 254.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 8904
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][NEUTRAL] OK, cause it's gonna verify some information really quick. Uh, can I get your date of birth, please?
[CUSTOMER][POSITIVE] Not a problem.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you and then can I get your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. Last thing I need is the email address we've got on file for you. uh, looks like it is a Yahoo account.
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][POSITIVE] Perfect. OK, thank you so much for verifying that. OK, and so this claim was for uh [PII]?
[CUSTOMER][POSITIVE] Not a problem.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, um, is she present that I could speak with her as she is the policy holder?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] No, ma'am, she's at work and all the other times I've called they haven't they I mean I'm her proxy I've been given.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All her, I guess.
[CUSTOMER][NEUTRAL] Whatever authority to talk to speak on her behalf and I'm actually the one that's filed all the claims with this cancer uh diagnosis.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Got you. OK, give me just a moment, let me take a look.
[CUSTOMER][POSITIVE] Not a problem.
[AGENT][NEUTRAL] OK, so, um, the most recent claim I have for her that was, uh, submitted [PII]. Does that sound right to you?
[CUSTOMER][NEUTRAL] Uh, yeah, I believe so.
[AGENT][NEUTRAL] OK, so it looks like.
[CUSTOMER][NEUTRAL] It says online it says it says pending but I, it hasn't it won't let me see any of the documents or whatever.
[AGENT][NEUTRAL] Sure, um, so it looks like it just completed processing yesterday, um, and when I say that I mean it's, um, the information has completed processing so we have now requested uh medical records so again that was most just sent out yesterday so then once we have that information we'll be able to continue getting this processed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] See, they told me that they requested those like.
[CUSTOMER][NEUTRAL] Monday they requested all those documents.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Because I talked to somebody a few days ago they, they said that that that that that request had gone out like Monday or something like that.
[AGENT][NEUTRAL] Yes, I think we're still waiting for that so I did look it looks like we got other claim information prior to this on [PII].
[AGENT][NEUTRAL] And I believe that's when that was first.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Requested. So I believe we're still waiting for that.
[CUSTOMER][NEUTRAL] Yeah they sent they sent me a deal and they sent I put the.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The doctor's information on it and send it back in that like the same day.
[CUSTOMER][NEUTRAL] Um, so we're just waiting on who are we waiting on to get records? Does it say or?
[AGENT][NEUTRAL] Um, yes, uh, so the doctor, I do see a note from yesterday that medical records request was sent to, um, Doctor [PII].
[AGENT][NEUTRAL] [PII], I'm sorry, I'm not sure how to [PII], OK, thanks. Yes, uh, so that information.
[CUSTOMER][NEUTRAL] [PII] yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, I, I don't know I don't know if that's the right way to say it either.
[AGENT][NEUTRAL] Oh that's whatever and you know who I mean that's what matters, um, OK, so the, the fax was, it was sent by fax, um, and it was confirmed that they received that information, so that was sent yesterday. Let's see, medical records request.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Pretty, pretty sure I sent in the the pathology report from her office.
[AGENT][NEUTRAL] OK, and.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, um, but with some of these it might be, uh, that we just needed that additional information from the physician, and that seems to be the case with this so we did, you know, it can depending on the physician of course and how they choose to send that information to us, uh, they can upload it, they can fax or they could send it by mail um I would still say a safe bet would be 7 to 10 business days.
[CUSTOMER][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] But it's completely up to them how they choose to send that information.
[CUSTOMER][NEUTRAL] Yeah, and is this regarding the uh.
[CUSTOMER][NEUTRAL] Like the fact that they say it could be preexisting or whatever.
[AGENT][NEUTRAL] Most likely, let me look at the effective date.
[AGENT][NEUTRAL] Yes, so I see this policy is effective date, yeah, go ahead.
[CUSTOMER][NEUTRAL] Yeah, cause all you
[CUSTOMER][NEGATIVE] But we had, but we had that, that's why I've asked other people before and then no one's been able to give me a real answer. She had a policy, the same policy two years previous.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For the past 2 years.
[CUSTOMER][NEGATIVE] And that's why the whole preexisting thing has thrown us for a loop because it's like, well, we've had the same policy.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] No, you're right, um, and again it may not even be that. Let me look at the original note.
[AGENT][NEUTRAL] Yeah, that's what it's showing, um, so yeah, that is, I, I understand the confusion. I think this is one that of course since it's, it's the same policy but it's a newer policy number and the effective date was [PII], um, so that's most likely why, but they generally don't take that long, um, especially for things like this for cancer, uh, those physicians, of course understand the, uh, gravity of this and how.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] that is and to get it to us in a timely manner um so I'd imagine they would either fax it right back or upload it to us so if you wanted to check back, of course you can still look on the website if you prefer um but you could give us a call maybe next week and check on it and you know we we'll see what we can find out for you but just so you've kind of got that expectation.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I might.
[CUSTOMER][NEUTRAL] OK, I might reach out to her office and just kinda.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] That's yeah just kind of.
[CUSTOMER][NEUTRAL] Ask them like hey can y'all can y'all get this going?
[AGENT][NEUTRAL] Mhm. Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, well I'll do that and I appreciate your help today.
[AGENT][NEUTRAL] Of course, yeah. Was there anything else I can help you with, [PII]?
[CUSTOMER][NEUTRAL] Uh, no, I need, I do have one question, um, so I know the policy covers like, um.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Chemotherapy
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Treatments and um like diagnostic things. So does that, would that mean like uh the colonoscopy and the CT scans?
[CUSTOMER][NEUTRAL] That we've had to do.
[AGENT][NEUTRAL] Yes, um, I can get that pulled up to see for sure typically with these kinds of policies it would cover one of those diagnostic tests a year, um, but I'm not, I know colonoscopy falls under that. I can check to see if, uh, CT.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Would fall under differently and then of course if a follow up was required after one of those that could be a separate benefit as well give me just a moment let me get this pulled up and we'll take a look.
[CUSTOMER][NEGATIVE] Yeah, I can't
[CUSTOMER][NEUTRAL] Yeah, because
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Because they had us do a CT and then they had the the oncologist had us follow up with a PET scan.
[AGENT][POSITIVE] Got you OK.
[CUSTOMER][NEGATIVE] Which was, which was rather rather pricey.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Alrighty, let me just a moment, let me find this.
[AGENT][NEUTRAL] OK, so the medical imaging test is different, um, so there's a diagnostic test benefit which is $50.01 test per calendar year, and then if a follow up for one of those is required again 1 per calendar year that pays $100. Medical imaging is different though that one pays it is still once a year, but that's up to $500. Uh, so let me see. I think CT should fall under that, but I'm sometimes they're a little bit specific, so give me just a moment I'll, I'll see for sure.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yes, so medical imaging that would of course be uh MRI, CT scan, CAT scan, or a PET scan. So that is a separate benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and what about the colonoscopy? Does that, is that like, did you say that was $50 or does it cover the whole cost?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] No, so that that would fall under the diagnostic testing benefit, uh, for colonoscopy, so that would be the $50.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All [PII]. Well, that answers my question. I'll, once I get those, uh, and then the chemotherapy, it covers like up to $15,000. Is that what, is that what I remember?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, um, and that's on a per calendar year basis, um, so how that works is it would, has she started chemo yet?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, she just, she just went for her 3rd treatment, uh, yesterday.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the way that that works uh for it's a 12 month period and that would begin the first time she receives that treatment. So that would be that 12 month mark from that first time. So it's 5 15,000 for that entire 12 month period and then it would replenish after that 12 month period.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Does that make sense?
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, yeah.
[CUSTOMER][NEUTRAL] Yeah, hopefully we don't have to hopefully we don't have to do another 12 month period of it, but.
[AGENT][NEUTRAL] No, hopefully not, but I, I just still like to make sure people are aware of how that works.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, and then how would I submit that claim just with a copy of the like the itemized chemotherapy bill?
[AGENT][NEUTRAL] OK, so yes, um, chemo radiation and immunotherapy, we would need that itemized statement that shows the diagnosis and procedure codes and of course you can get that from wherever she went for treatment. In addition to that though for chemo, we would also need the explanation of benefits from primary insurance, uh, and again the provider will have that wherever she went it's essentially just showing that whoever y'all have as major medical that they did help.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] OK, what if they don't help?
[AGENT][NEUTRAL] Um, we would need that information.
[CUSTOMER][NEUTRAL] OK, because our, we are, we're part of uh a private healthcare system.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And we're actually in an appeals with them right now because they're saying her cancer was diagnosed or preexisting when she hadn't even been diagnosed until December. And they're saying, oh, it, you know, the.
[AGENT][NEUTRAL] Oh.
[AGENT][POSITIVE] Oh my gosh.
[CUSTOMER][NEUTRAL] It's so we're we're in an appeals. I get to call and yell at them here a little later today, so, um, hopefully that'll that'll get everything going, yeah, oh it's gonna be. I just gotta be very careful. I gotta watch my, I gotta watch my language a little.
[AGENT][NEUTRAL] That could be therapeutic.
[AGENT][NEUTRAL] I'm so sorry you have to deal with that on top of.
[AGENT][NEGATIVE] Yes, that's awful though on top of everything else that you have to deal with it.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] And so like, so if they, if they officially deny our appeal, I would just have to show you that show y'all that it's been denied and they're not assisting with it basically.
[AGENT][POSITIVE] Yeah, we'll we'll do what we can to help you with all of that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] All right, well, I just gotta make some mental notes of that and then uh once I have that information I'll submit it online.
[AGENT][NEUTRAL] Sure. OK.
[CUSTOMER][POSITIVE] All right. Thank, thank you for your help today. You've been great.
[AGENT][POSITIVE] But if you have any other questions don't hesitate. Absolutely it's very confusing and you know we wanna do what we can to help. I hope you'll have a great rest of your day.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Alright thank you bye bye.
[CUSTOMER][NEUTRAL] Uh, uh huh bye bye.