AccountId: 011433970860
ContactId: 48eba185-fdd3-4266-8ac2-2ce476d446e5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 888179 ms
Total Talk Time (AGENT): 322188 ms
Total Talk Time (CUSTOMER): 207919 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/29/48eba185-fdd3-4266-8ac2-2ce476d446e5_20250529T15:06_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Um, yes, hi. I have a question about, um, what my policy covers, um, in terms of a surgery.
[AGENT][POSITIVE] OK, I can definitely help you with your surgery coverage. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII] [PII].
[AGENT][NEUTRAL] Thank you for that and [PII], may I have a good contact number in case we're disconnected? I'm sorry, your policy number.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You know I'm not sure I'm looking at my dashboard.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And for every claim, it looks like a different policy number, so I'm, I'm very confused.
[AGENT][NEUTRAL] For every claim, it looks like a different policy number. OK, um, well, what's one of the policy numbers that you see and maybe that'll, I just need one and I should be able to get to all of them.
[CUSTOMER][NEUTRAL] Yeah, so
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] 252-247-2
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] You know what, hold on one moment. I think my system just went down. Hold on one moment.
[AGENT][NEUTRAL] And Ms. [PII], do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Maybe that's what's happened. Maybe it went down before. Maybe that's why all my lines were out or were down.
[AGENT][NEUTRAL] Alright, let's try again.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, thank you so much for holding. I apologize for that wait. My system went down, um, but I have everything back up here and um I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, uh, [PII].
[CUSTOMER][NEUTRAL] [PII] and [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And you said you wanted to go over surgery benefits?
[CUSTOMER][NEUTRAL] Yeah, uh-huh.
[AGENT][NEUTRAL] OK, hold on. And what type of um
[AGENT][NEUTRAL] Surgery is it?
[CUSTOMER][NEUTRAL] It's a, a revision following mastectomy, so it would be a liposuction and revision.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So let's see.
[AGENT][NEUTRAL] OK, so for mastectomy, confinement, um,
[AGENT][NEUTRAL] Surgery and then prosthesis. The, for the consignment, the policy will pay up to $50 per day.
[AGENT][NEUTRAL] The surgery would pay up to $25 per surgery.
[AGENT][NEUTRAL] And whether surgical or non-surgical for, um, hold on one second.
[AGENT][NEUTRAL] OK, it's the same benefit. It will pay up to $25.
[AGENT][NEUTRAL] For any um prosthesis or um orthotics that if it's needed.
[CUSTOMER][NEGATIVE] OK, wait. Uh, this isn't making any sense.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] I've already had a full mastectomy and a full reconstruction.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Now we need to go back and do a revision, so.
[CUSTOMER][NEUTRAL] They're gonna do liposuction.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Fat transfer.
[AGENT][NEUTRAL] So outside of the
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Outside of the mastectomy, just your surgery benefits in general, the policy pays up to $45 per unit. So depending on each surgery has a number of units that it's worth. So, however many units it is, the policy will pay up to $45 per unit with a max of $4500 per operation. So,
[AGENT][NEUTRAL] It won't go over that amount. Um, if anesthesia is needed, the policy will pay up to 25% of whatever is paid towards the for the surgery.
[CUSTOMER][NEUTRAL] Whatever I pay or insurance pays.
[AGENT][NEUTRAL] Well
[AGENT][NEUTRAL] No, whatever insurance pays. So if we pay $45 towards the surgery, anesthesia would be 25% of that $45.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And per unit, what is a unit of what? I don't understand what that is.
[AGENT][NEUTRAL] Well, that would be on the coding, so you wouldn't know, um, depending, so let's say it's 10 units per surgery. I, I don't know what determines the units. Each unit has a, each surgery has a certain number of units that is worth. So we'll get that when we get the billing and then we'll just multiply however many units it is by 45, but we won't pay over $4500.
[AGENT][NEUTRAL] Towards the operation.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I really don't know. Uh, so there's no way for me to know?
[AGENT][NEUTRAL] Um, you can call the typically the the insurer wouldn't ask that, um, but you can call them and see, I guess, how much, how many units is this surgery, um, and they could possibly answer. It's usually sent to us on the itemized billing and we just calculate it.
[CUSTOMER][NEUTRAL] I mean,
[CUSTOMER][NEUTRAL] Uh, um, OK, um, I, I have a question about an as I was looking at.
[CUSTOMER][NEUTRAL] What's already been paid to me, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Looks like my mastectomy.
[CUSTOMER][NEUTRAL] Uh, there's a note on there, so it was.
[CUSTOMER][NEUTRAL] Two different surgeons doing two different things, right? It was a
[CUSTOMER][NEUTRAL] The full mastectomy by one surgeon, and another surgeon came in and did a reconstruction.
[CUSTOMER][NEUTRAL] And there's a note on there.
[CUSTOMER][NEUTRAL] It looks like I possibly could be.
[CUSTOMER][NEUTRAL] Could qualify for further payment?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Something about 2 incision points or something.
[AGENT][NEUTRAL] Like
[AGENT][NEUTRAL] Are you looking, I don't, are you looking on something from the hospital or your explanation of benefits from, I'm just trying to get to where you are.
[CUSTOMER][NEUTRAL] My, um, explanation of benefits. It's on my dashboard here. The surgery was uh 7-1124.
[AGENT][NEUTRAL] 711, hold on one moment.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Now, uh, are you looking from
[AGENT][NEUTRAL] APL or from your major insurance?
[CUSTOMER][NEUTRAL] APL.
[AGENT][NEUTRAL] OK, hold on one moment let me pull that up.
[AGENT][NEUTRAL] Because all the ones, let me see if this is it.
[AGENT][NEUTRAL] OK, this is processed under another policy. Hold on one second, let me.
[AGENT][NEUTRAL] Alright, so these for [PII] were processed under um your former policy, so that's why I wasn't able to access it. Hold on one second, I'm gonna
[AGENT][NEUTRAL] Pull that policy up and then I can get to the claim.
[AGENT][NEUTRAL] OK, and is your claim number 3536552?
[CUSTOMER][POSITIVE] Um, that sounds right. It just locked me out. That sounds right though.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] I'm on the claim now. I'm just looking at the, we paid it out, but I'm looking for the denial reason. Hold on one second.
[AGENT][NEUTRAL] OK, so there were 2 surgery procedures of the 2, we paid the most expensive we paid towards the most expensive procedure.
[CUSTOMER][NEUTRAL] OK. And does that mean that
[AGENT][NEUTRAL] So that's just saying we
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] So I'm not, I'm not possibly do additional payments on that.
[AGENT][NEUTRAL] No, that's just saying on this claim, there were two different codes, two different surgery codes that were used. So of the two, we paid towards the 50,000 versus the 3700.
[CUSTOMER][NEUTRAL] And you can only pay one of the two.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, so I, I can't, I'm not do anything else on that.
[AGENT][NEGATIVE] Um, no, ma'am, not for, not for this claim, no.
[AGENT][NEUTRAL] Every the other two codes were paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I have to find out how many units.
[CUSTOMER][NEUTRAL] Of the surgery.
[AGENT][NEUTRAL] If you
[AGENT][NEUTRAL] Yeah, if you're trying to figure out like how exact well, it's gonna be hard to get an exact, but an estimate, I guess if you're trying to figure out exactly what your policy will pay towards the surgery.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, that would be the, the only way because it's 45 per unit. So depending on how many units the surgery is.
[CUSTOMER][NEUTRAL] OK. And then anesthesia is 25% of what the insurance pays.
[AGENT][NEUTRAL] Mhm. 25% of the actual cost that we pay towards the surgery.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, I will try to figure that out.
[CUSTOMER][POSITIVE] All right, well thank you very much.
[AGENT][POSITIVE] You're very welcome. Well, was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] I don't think so. Thank you.
[AGENT][POSITIVE] You're welcome. Well, thanks for calling APL and I hope you have a good day.
[CUSTOMER][POSITIVE] Thanks you too.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Mhm. Bye-bye.