AccountId: 011433970860
ContactId: 4c6799d3-8b8e-4c5a-97c2-d7c8836945ba
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 489250 ms
Total Talk Time (AGENT): 125302 ms
Total Talk Time (CUSTOMER): 263032 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/15/4c6799d3-8b8e-4c5a-97c2-d7c8836945ba_20250415T13:46_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], I, um, usually don't call. I usually email the care team for claim updates. I'm calling from an agent's office, um, and so I don't know if I've gotten the right.
[CUSTOMER][NEUTRAL] Area but um I did email them yesterday and the agent is hoping to get an update this morning so I thought I'd just try to give a call and see what I can confirm.
[AGENT][NEUTRAL] OK, um, do you have, what is your name and do you have a good callback number?
[CUSTOMER][NEUTRAL] Yes, name [PII]
[CUSTOMER][NEUTRAL] Callback number is gonna be [PII].
[CUSTOMER][NEUTRAL] 607.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And [PII], do you have the policy number of the member?
[CUSTOMER][NEUTRAL] I do.
[CUSTOMER][NEUTRAL] Yep, I am showing policy number is 2151581.
[CUSTOMER][NEUTRAL] And I'm hoping that'll pull up a cancer or a critical illness policy for.
[CUSTOMER][NEUTRAL] Last name [PII] and.
[CUSTOMER][NEUTRAL] Uh, first name [PII].
[AGENT][NEUTRAL] And do you have his birth date?
[CUSTOMER][NEUTRAL] Um, let me, I can pull, I think that's on the APL website. Let me just get logged in here real quick.
[CUSTOMER][NEUTRAL] Because I did not submit this claim directly so I'm just wondering if you even got what you need, see here.
[AGENT][NEUTRAL] Um, while you're doing that too, can you confirm an email address for me?
[CUSTOMER][NEUTRAL] Yeah, um, uh, email [PII].
[CUSTOMER][NEUTRAL] At war, W A R E.
[CUSTOMER][NEUTRAL] Group
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you, [PII].
[CUSTOMER][NEUTRAL] Yeah, no problem. I just logged in. I'm seeing the last 4 of a social, but I don't think I'm able to access a date of birth.
[AGENT][NEUTRAL] OK, that's OK.
[CUSTOMER][NEUTRAL] Unless it's listed on his policy.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Um, what date are we checking on for him?
[CUSTOMER][NEUTRAL] So what I was reached out to me the um the his employer reached out stating um that [PII] submitted a claim for his critical illness policy with APL for a cancer diagnosis that took place in [PII].
[CUSTOMER][NEUTRAL] And then I get, and then it just follows the APL notified him that the only thing covered in his claim is a health screening. So I guess.
[CUSTOMER][NEUTRAL] I didn't know if you were provided enough to determine if this was just not a covered illness or maybe a pre-X or maybe you've just not gotten enough information. I didn't know what maybe you've received and if you're missing any forms that we could submit.
[AGENT][NEUTRAL] Let me pull up what we got.
[CUSTOMER][NEUTRAL] Thank you. Yeah, so unfortunately, I would assume that it would have been submitted fairly recently, but I know that it would have been, it says cancer diagnosis and surgical procedure that took place in [PII]. But that's about all I got.
[AGENT][NEUTRAL] Yeah, I see we've got something at the end of March. Let me see why he submitted.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, I'm pulling up that document. Just give me one moment.
[CUSTOMER][POSITIVE] Appreciate it.
[CUSTOMER][NEUTRAL] Very likely you just got info for a wellness.
[AGENT][NEUTRAL] Yeah, um, let's see, so.
[AGENT][POSITIVE] We got some looks like, OK, so we got some benefits of summary from the uh.
[AGENT][NEUTRAL] Looks like he printed these off from
[AGENT][NEUTRAL] Maybe like a portal for his hospital account.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I didn't know, do you know, and I know you're gonna be limited to what you can tell me. Do you, do you see that you may have received at least have you received all of the forms necessary for the, for the critical illness diagnosis?
[AGENT][NEUTRAL] What we might be missing is diagnosis codes.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Marks they put on the denial.
[CUSTOMER][NEUTRAL] Yeah, I assume it probably did say something on the letter as to what you might need.
[AGENT][NEUTRAL] Yeah, typically, so what we're looking for, I don't see any diagnosis is listed on any of these claims.
[AGENT][NEUTRAL] Or they're not.
[CUSTOMER][NEUTRAL] So probably like a pathology report.
[AGENT][NEUTRAL] Yeah, I was looking for like a pathology report. We really need the diagnosis to determine if any additional benefit is payable. Most of these, these, these printouts, again, it looks like they're probably from like a hospital portal, and those don't typically contain the diagnosis codes. It does have the procedure codes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But I don't see any diagnosis codes on here and that's kind of the missing factor of what we need to make a determination for further benefits.
[CUSTOMER][NEUTRAL] Yeah, that makes perfect sense and it looks to me like this would be like a one lump sum upon diagnosis. We're not necessarily gonna be able to get him benefits on any type of surgical procedure. It would have to be basically um we need to just show the diagnosis. We don't really need to show anything else. Perfect. And then I believe, let me see here. I think I was just gonna pull up the.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] Yeah, that's correct, yeah.
[CUSTOMER][NEUTRAL] Claim form and I believe there's is there there's a physician's portion I believe that needs to be completed as well.
[AGENT][NEUTRAL] Yes, and it looks like on this, we didn't.
[CUSTOMER][NEUTRAL] I didn't know if that
[AGENT][NEUTRAL] I'm not seeing where he completed.
[AGENT][NEUTRAL] Any claim form. He just simply sent in the printouts from his hospital portal.
[CUSTOMER][POSITIVE] Perfect. Perfect. That makes sense. So from that, you were probably able to kind of see, oh, we have a, a wellness screening here, blood work or something, and then that was, so from what he did provide, you were able to pay that. But otherwise, um I'm gonna let him know we need just to go ahead and get him the whole full claim forms to get completed and then provide a pathology report showing the date of diagnosis would be probably the, the best thing, um.
[AGENT][NEUTRAL] So if we can get that too.
[AGENT][NEUTRAL] I
[AGENT][POSITIVE] Yes, absolutely.
[CUSTOMER][NEUTRAL] And then is it, am I correct in that they can, if they do provide the pathology report, they don't necessarily need to have the physician's form completed or should we go ahead and have both of those done?
[AGENT][NEUTRAL] Um, if you could just go ahead, just to be on the safe side and be thorough, can if you if the claims or the forms completed, that would be great.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Perfect. Alright, well, I really.
[AGENT][NEUTRAL] We we don't.
[CUSTOMER][POSITIVE] That I do. I appreciate it so much. I that makes perfect sense. I'll make sure to get him all the claim forms let him know what is needed, and uh go from there. So thank you so much again.
[AGENT][POSITIVE] OK, well thank you for calling APL. I hope you have a great day, [PII].
[CUSTOMER][POSITIVE] You as well thanks so much bye bye.
[AGENT][NEUTRAL] All right.