AccountId: 011433970860
ContactId: 401e2354-555e-4f23-9dce-fb7991d5a999
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1395270 ms
Total Talk Time (AGENT): 975618 ms
Total Talk Time (CUSTOMER): 305969 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/12/401e2354-555e-4f23-9dce-fb7991d5a999_20250212T20:45_UTC.wav
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[AGENT][POSITIVE] Thank you for calling ATL. You're speaking with [PII]. How may I help you today?
[CUSTOMER][NEUTRAL] Yes [PII], I just need some clarification on some payments claims that I got and how I need to move forward to what to send y'all.
[AGENT][NEUTRAL] OK. First, give me your name.
[CUSTOMER][NEUTRAL] I need help.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What's your name?
[CUSTOMER][NEUTRAL] Uh [PII]
[AGENT][NEUTRAL] All right, Miss [PII], what's your phone number just in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] All right. And what's that policy number, Miss [PII]?
[CUSTOMER][NEUTRAL] Um, 00927039.
[AGENT][NEUTRAL] All righty, I have it. All right. And just verify your date of birth and your mailing address for verification.
[CUSTOMER][NEUTRAL] Uh, [PII] and [PII], that's in [PII].
[AGENT][NEUTRAL] And what about the email address on file?
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][POSITIVE] Alright, thank you for that information and you have some question about some explanation of benefit that you received is that correct?
[CUSTOMER][NEUTRAL] Uh, yes, and it's, uh, I do just clarification.
[AGENT][NEUTRAL] OK, go with the
[AGENT][NEUTRAL] OK, go with the first claim number you want me to look at.
[CUSTOMER][NEUTRAL] Um, let's see, where's the claim number on it.
[AGENT][NEUTRAL] It's gonna start with a 3.
[CUSTOMER][NEUTRAL] OK, 349-0297.
[AGENT][NEUTRAL] OK, let me bring up that one. All right, what is your question on that one?
[CUSTOMER][NEUTRAL] OK, can you just kind of explain to me like it says uh not covered because um.
[CUSTOMER][NEUTRAL] I wasn't where did it, where did I read that, um.
[CUSTOMER][NEUTRAL] Oh, on the one on number 4 and 5 like that was on 36, it says that the maximum reconstruction benefit has been met.
[AGENT][NEUTRAL] Uh-huh, it's a maximum amount that that says payable, so you said that's on date of [PII], uh-huh, yes, ma'am. Uh.
[CUSTOMER][NEUTRAL] That's not
[AGENT][NEUTRAL] I can bring up your.
[CUSTOMER][NEUTRAL] So it's the max reconstruction is that per year or is that per policy?
[AGENT][NEUTRAL] Let me read, let me, let me bring up your policy and let you look at that benefit.
[AGENT][NEUTRAL] 00927039.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And and it's data service 36, right? Yeah.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, yeah.
[AGENT][NEUTRAL] REM. I'm trying to get to which one of those told you that I can find it administrator, administrator lab.
[AGENT][NEUTRAL] What, what's the code on the end of that for me? Give me that code number D1E what?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] D1E0049
[AGENT][NEUTRAL] Oh, no, that's telling you that we need the itemized surgery bill for consideration to be able to pay that. You need to get that from your doctor.
[AGENT][NEUTRAL] We need the itemized surgery bill for that to be reviewed. That's what they're telling you. So you'd have to ask your uh surgeon for the itemized surgery bill with the surgery code on it and the amount. Well, they got the amount, but you must have sent in, uh, let me see if they have the amount. No, they don't have the amount for 36 that D1E302 and that uh that's asking you for the itemized surgery bill.
[AGENT][NEUTRAL] And then at DE I'm sorry, and now that DE 249 for data service 321 also asking for the itemized surgery bill.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so I need that from my doctor.
[AGENT][NEUTRAL] But to get the out of my surgery bill, it won't be on the facility bill. It won't be where you had it done at. The surgeon charged a separate bill and the facility charged a separate bill. So they need the surgeon bill with the date of service, the surgery code, and the amount he charged you.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so I need that from the surgeon. OK, what about the DE10049?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEGATIVE] That's the itemized surgery bill too. They just use two separate codes, but that's what they're telling you also. And on that explanation of benefit, it don't read that on you, they're telling you what we need. It should tell you on there what we're needing.
[CUSTOMER][NEUTRAL] Well, it's on this on that 49 it says the maximum for the reconstructive best breast surgery benefit has been met. I didn't do, I mean, I years ago I did re.
[AGENT][NEUTRAL] Let me look at that. Uh let me see what that is. DD1E 249. OK, let me look it up and see what they say. C O R E M.
[AGENT][NEUTRAL] 249. OK, that was 49, you want 249.
[CUSTOMER][NEUTRAL] No, I want 49.
[AGENT][NEUTRAL] 49 is the automatic surgery bill. You said DE 249.
[CUSTOMER][NEUTRAL] 04
[CUSTOMER][NEUTRAL] So, on my paper that I have the 249 says that they need um.
[CUSTOMER][NEUTRAL] An itemized statement on the 049 is when there's talk.
[AGENT][NEUTRAL] Oh, the maximum for this construction. OK, so let me go to your policy and it said the maximum been met and I can tell you if it's, uh, for the maximum for the, for that, for that, that particular surgery or is it for the maximum for the year? Let me bring up your policy. I see what you're saying.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] No because you have been met. OK, so let's go to your, uh, reconstruction do they have it on here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I'm trying to get to the schedule page of your policy.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, I see you and let me see.
[AGENT][NEUTRAL] See.
[AGENT][NEUTRAL] When did they pay it? That's what I'm trying to see when did they pay it.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, and now preventative.
[AGENT][NEUTRAL] Reconstructive and um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] No cyst. OK.
[AGENT][NEUTRAL] Give me one second. I'm just looking at some CEO.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] SJPQ OK 0.
[AGENT][NEUTRAL] 2
[AGENT][NEUTRAL] 703-92024.
[AGENT][NEUTRAL] Surgery.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 223.
[AGENT][NEUTRAL] OK, so 2004, so I'm still.
[AGENT][NEUTRAL] You too.
[AGENT][NEUTRAL] And the data service 306-2024.
[AGENT][NEUTRAL] OK, surgery, yeah, they're talking about for that date of service [PII]. That's what they're talking about for that date of service. They paid you the maximum amount that can be paid for that date of service on [PII].
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] The maximum amount for that data service for that surgery, that's what they're talking about, the benefit that met for that data service for that particular surgery.
[CUSTOMER][NEUTRAL] OK, but.
[AGENT][NEUTRAL] OK. But I
[CUSTOMER][NEUTRAL] I have reconstructed breast surgery on that day.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You did.
[CUSTOMER][NEUTRAL] No, ma'am, I did not.
[AGENT][NEUTRAL] OK, let me see. Well, let me see, I put up surgery. Let me see what, let me go back to this, and I put 30AQ.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] C L A H Q. Let me put in that date again.
[CUSTOMER][NEUTRAL] And I start calling surgery breast.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] 4 and we pay uh uh on 36 we pay $37.95 for surgery and your [PII] was $948 for data service 36. That's what we pay on that. And then on 36 they're asking you for the itemized uh.
[AGENT][NEUTRAL] Surgery bill, I guess it's some additional information they need cause that D1E302 is asking for the biopsy itemized surgery bill.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So, yeah. So they have paid you a surgery benefit on 36. And then they're asking you for uh additional information for that surgery and they got biopsy, so you need to send that in. But the code that we paid the surgery bill was that uh procedure code 38505.
[CUSTOMER][NEUTRAL] OK, so that's uh so that was on on another claim form.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes, ma'am. That was on uh claim number 350,930. Mhm.
[CUSTOMER][NEUTRAL] OK, so they are still needing a itemized statement from my surgeon, is that correct for that day?
[AGENT][POSITIVE] Uh, that's correct. That's right. That's what they're asking for.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] OK, um,
[CUSTOMER][NEUTRAL] OK, I guess that's just in the wording, so, OK, so I can get an automatic statement from my surgeon. OK, next question on um the other claim. I think it looks like you have it pulled up but the 3,506,930.
[AGENT][NEUTRAL] Uh-huh. What about it? OK.
[CUSTOMER][NEUTRAL] So the transportation benefit is that is is that if I'm just in the hospital or is that me going back and forth um to my daughter what is.
[AGENT][NEUTRAL] Transport uh uh transportation only pay if you have chemo, surgery, uh, radiation, uh, inpatient, like that, not for office visits. And for the transportation, if you travel for surgery more than 50 miles or more, they, if they denied it.
[AGENT][NEUTRAL] And you, you, you, you travel more than 50 miles or more, you can send in the facility bill with the address to the facility for us to be able to determine if the benefits are payable. and let me see on here that they do transportation and did they do a map out here because we have to, we, we check the transportation.
[AGENT][NEUTRAL] So if they so if they didn't have the address to check then you would need to just submit that in. But what, what, whatever facility you went to because any time we do a claim and you have one of those treatments that pays for transportation.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We automatically go and check on Google. We put in your address and we put in the facility or the surgeons uh address to uh determine if you went 50 miles or more. So did you travel 50 miles or more?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK, so just send in the address, make sure you write down the address, and on the claim form, and I don't know that you fill out a claim form for the one you sent in, but on the claim form they have transportation and then you put your information and the facility address information on there and I don't know did you put that on your claim or not.
[CUSTOMER][NEUTRAL] Uh, probably did not.
[AGENT][NEUTRAL] OK. Well, that's what you, well that's to be reviewed. That's all you have to do. Mhm.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so can, can it be just me literally writing it there or do I need to have something that proves that? I mean like.
[AGENT][NEUTRAL] No, you can, you write it, you can write it, you can write where you went to. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, alright, next question, and this may be too broad of a question so but so.
[CUSTOMER][NEUTRAL] I have, excuse me, obviously I have cancer. Um, I am on a treatment that's not considered chemo. It's the chemo pill that I do in my home, so I know that's not covered. But I do about every 6 weeks, I have, go into the hospital and I have a thoracentesis which has my um lung drained. Can you tell me how that is, I mean, I know not, you know, specific, but because what do you need to have any of that covered?
[CUSTOMER][NEUTRAL] As far as having my lung drained.
[AGENT][NEUTRAL] Uh, now long grain wouldn't be covered because that's no kind of procedure. I mean, but you can send it anything for review if you get an itemized bill and you want us to review it, send it in because there's no guarantee to pay over the phone, but you can send in any claim to be reviewed.
[CUSTOMER][NEUTRAL] OK, but that is not a procedure that normally covered. I mean, I know you I can send it in and they will.
[AGENT][NEUTRAL] I know, I would know until you send in the in the medical treatment for us to review about your policy. But from the sound of it, it doesn't sound like it'll be something that would be covered. But you can send it in for review because like I said, there's no guarantee to pay on the phone, and we don't want to say what is covered or not covered without me looking at a claim with the information on it. So if you want to review, submit it. Yes ma'am.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, so when I submit that, what, what do I need to submit with it? What kind of documentation do you need?
[AGENT][NEUTRAL] To you need the itemized bills whatever they did, whatever procedure they did you need the date of service, the CPT code for that date of service, what they did for you and the amount they charge, and that's how we can determine if that's the cover benefit on this policy.
[CUSTOMER][NEUTRAL] OK, and then itemized, uh, I guess that itemized needs to be from the surgeon and from the hospital?
[AGENT][NEUTRAL] Yes, ma'am. If it's a procedure whether it was a surgery, we will need to automatic surgery bill. If it's a procedure that was done at the facility and the facility is charging you, you can send the facility bill in for review to see if it's gonna be, you know, whatever was done was payable.
[CUSTOMER][NEUTRAL] OK, can you do tell me a rough overview of what benefits my policy does cover as far as cancer?
[AGENT][NEUTRAL] Yes, ma'am. I, I got your policy up. Yes, ma'am. All right. So, if you're in the hospital related to cancer, it pays $100 per day for each day that you're in the hospital.
[AGENT][NEUTRAL] If you're in the hospital and they give you some kind of drug that's covered on the policy, uh, for inpatient drug it's $150 per confinement. If it's outpatient where you have something done like chemo or radiation or surgery, it's $50 per prescription, a maximum of $50 per month.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You got surgery benefit? Go, go ahead. OK, I will, I will. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hold on one second. I got.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] I'm so sorry.
[AGENT][POSITIVE] Oh, that's all right. Just take, take your time. You OK?
[CUSTOMER][POSITIVE] Yeah, I'm good.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Oh my goodness.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I know. Oh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah. You know that RSV going around and stuff, so yeah, just be careful. Yeah.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][POSITIVE] OK, continue, please. I'm sorry.
[AGENT][NEUTRAL] That's all right. And you know you have surgery benefit and that's based on the surgery code. We have to have that information to give you a benefit about surgery, uh, you know, the amount and stuff, but it, you do have surgery benefit. You have benefit, if you have to have surgery, you want a second opinion.
[AGENT][NEUTRAL] It'll pay a $300 benefit for a second opinion and if you needed a third opinion, it'll pay an additional $300 for a third opinion. You know, if you want that, you know, you had surgeon you concerned about it you say I want a second opinion or I want a third opinion.
[AGENT][NEUTRAL] If you have surgery and it's done on an outpatient basis, you would pay that, we would pay a $200 benefit for the facility charge. And that's for example, say you had to go in there, you had to have breast surgery and you went to the hospital and that's where they did the surgery. That benefit for the facility is $200. That's a different benefit from the surgery benefit.
[AGENT][NEUTRAL] Anesthesia benefit is 25% of whatever we pay on the surgery benefit.
[AGENT][NEUTRAL] Attendant physician benefit is $30 per day. So if you're in the hospital and your physician come by the house while you're in there, uh, two days that you get $30 for each day for that physician came by and see you in the hospital. It's called a attendant physician fee.
[AGENT][NEUTRAL] You have a prosthetic benefit. It's $1000 per device, including surgery fee, a maximum of 1 device per site up up to a lifetime maximum of two devices per covered person.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] You have a prosthetic prosthetic benefit. So that means if you have to get a wig, we'll pay $50 per hair per wig up to 2 maximum per lifetime on this policy.
[AGENT][NEUTRAL] You have blood plasma and platelet benefit. It's $150 per day. So if you had to get blood treatment, it's one of the blood treatment or platelets or platelets that's on our policy, it pays $150 per day for each day that you had blood uh tablets uh benefit in a maximum of $75 7500 dollars per calendar year.
[AGENT][NEUTRAL] Radiation, chemotherapy, chemotherapy is $500 per cal in a month. So say if you had chemo, either radiation, chemotherapy, whichever one you had, instead of be all together when you got through with the month, say it was $8000 but the most we're gonna pay is $500 per calon a month.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You have home therapy benefit, $50 per treatment up to 12.
[AGENT][NEUTRAL] Per calendar year hormone therapy treatment. That's what I meant to say, hormone therapy treatment. It's $50 per treatment and it's 12 treatments per calendar year.
[AGENT][NEUTRAL] You have bone marrow, stem cell transplant benefit, $500 per calendar year. The non-autogluba is $1,500,000 per calendar year.
[AGENT][NEUTRAL] Experienced treatment benefit paid in the same manner and under the same maximum as any other treatment in the scheduled benefits.
[AGENT][NEUTRAL] Dread diseases benefit is $100 per day of hospital confinement up to $90.90 days per confinement.
[AGENT][NEUTRAL] Uh, you have donor benefit. no, you don't have donor benefit. You have ambulance benefit, $200 per crib for ground. A is $2000 per crib. Pay up to 2 crips per hospital combinement for any condition, any combination of air and ground ambulance transportation. Then you have the transportation and lodging benefit.
[AGENT][NEUTRAL] It's 40 cents per mile as long as you travel 50, 50 miles or more and it's $1000 I mean 1000 miles per round trip.
[AGENT][NEUTRAL] And then you have outpatient lodging $50 per day, up to 50 days per year. So if you had to travel and was more than 50 miles away and then you decide to do a lodging not to come home every day cause it could be like 200 miles away and you decide to spend the night in a lodge in a hotel, it's $50 per day, up to 50 days per calendar year.
[AGENT][NEUTRAL] And you also have family lodging and the same amount is for the family lodging and transportation. You have hostage care, so if you get sick and you have to be put in hospitals, it's $50 per day, up to a lifetime maximum of $9000 per covered person. Home health is $100 per day.
[AGENT][NEUTRAL] Up to uh the same number of days you paid in the hospital. So if you were in the hospital for 4 days and then you had to get home here, it'll pay $100 a maximum up to the same day that you was in the hospital, for example, 4 days.
[AGENT][NEUTRAL] You know about your preventive diagnostic testing for like a wellness like a mammogram, Pap Smith colonoscopy, PSA, uh, uh, mammogram, it's $50 per calendar year. It's one wellness per calendar year.
[AGENT][NEUTRAL] Then you have physical therapy or occupational therapy, uh, or speech therapy is $25 per visit up to 4 visits per calendar year and that is your benefits on your policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, awesome. OK, is, uh, real quick on the, uh, preventative, is an MRI or like a PET scan, is that considered preventative or is that a, a different procedure?
[AGENT][NEUTRAL] Mm, it would be, it would be considered different to see if you had that coverage, but since you don't have an image benefit, if you have an MRI CAT scan, or PET scan, you can send it in under the wellness because we could pay it under the wellness as long as that when they cover benefit on your policy and you do not have medical image benefit on your policy.
[CUSTOMER][NEUTRAL] Or do you know?
[AGENT][NEUTRAL] And it would be considered the same one wellness per cal in a year. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright, well, I sure appreciate your help very much and well if I can't get all these things sent in.
[AGENT][NEUTRAL] Um
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] All right. Well, anything else I can help you with today, Ms. [PII]?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] I think I'm good I appreciate it very much.
[AGENT][POSITIVE] All right, well, take care of that cough now and you have a wonderful day. Thank you for calling American Life. Bye-bye.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Uh