AccountId: 011433970860
ContactId: 50784a9a-92a3-4a57-8474-571dbb703567
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1171410 ms
Total Talk Time (AGENT): 216257 ms
Total Talk Time (CUSTOMER): 691355 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/06/50784a9a-92a3-4a57-8474-571dbb703567_20250306T16:33_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][POSITIVE] Hey [PII], it looks like I'm just getting you today, lady.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, uh, this is a cancer policy and I have an insured husband on the phone and I did get permission from her and I'm gonna email, uh, the third party authorization form.
[AGENT][NEUTRAL] OK, what's the policy number?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] It's 532-280.
[AGENT][NEUTRAL] For [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am, and it's on the claim number 3,566,020.
[CUSTOMER][NEUTRAL] And he's inquiring about the chemo benefit for [PII] where it says that Max the benefit for the year and he's explaining that they have an extra chemo uh rider which pays an additional 10,000. He was saying that they hadn't met the
[CUSTOMER][NEUTRAL] Uh, benefit since it's actually 20,000 instead of 10,000 as far as chemo.
[AGENT][NEUTRAL] OK, let me check real quick.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEGATIVE] That's one thing I hate about when it gets warm, all these dang bugs.
[AGENT][NEUTRAL] Yeah, they do have the writer. Let me see when let me process this claim.
[AGENT][NEUTRAL] Yeah, this is um the same on this one as well. We'll have to send a request to the examiner to reprocess the claim.
[AGENT][NEUTRAL] So, uh,
[CUSTOMER][NEUTRAL] OK. So, go ahead. I'm sorry.
[AGENT][NEUTRAL] I can speak with him or you can let him know that um we do show that he does have the additional rider benefit and we'll send a request to have the claim reprocessed.
[CUSTOMER][NEUTRAL] OK, if you would explain that to him, um, because he, he, he said he has let uh everyone know he has a list of people he spoke to about it and um it still hadn't been taken care of, so.
[AGENT][NEUTRAL] OK, let me check notes real quick. Let me see who.
[CUSTOMER][POSITIVE] Cause he'll spell out the names and he got mine on there.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Huh, I don't see anything in regards to the additional.
[AGENT][NEUTRAL] Benefit ride or disgust.
[AGENT][NEUTRAL] Yeah, I don't see.
[CUSTOMER][NEUTRAL] Yeah, I looked and I didn't see anything either.
[AGENT][NEUTRAL] I see, OK.
[AGENT][NEUTRAL] You can send them to me.
[CUSTOMER][POSITIVE] Awesome and um like I said I spoke to his wife and she gave us permission. I'm gonna send out a third party for him, OK?
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Awesome, thank you, ma'am. Have a great one. Bye.
[AGENT][POSITIVE] Thanks you too.
[AGENT][NEUTRAL] Claims department, this is [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Yes, you're calling in regards to the claim for chemo received in [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK. I do show that this policy does have an additional benefit rider. We'll submit a request to get the claim reprocessed. Was there anything else that I can assist you with today?
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEGATIVE] Yes, ma'am. Uh, do, I am, I'm having a hard time from.
[CUSTOMER][NEUTRAL] Getting all the uh
[CUSTOMER][NEUTRAL] Chemos that were done.
[CUSTOMER][NEUTRAL] From the EOB.
[CUSTOMER][NEUTRAL] And from the provider, from the doctor himself.
[CUSTOMER][NEUTRAL] So, do you need this to go through Medicare?
[CUSTOMER][NEUTRAL] For an EOB or do, do I need to supply.
[CUSTOMER][NEUTRAL] The, the charges from the doctor for each individual chemo.
[AGENT][NEUTRAL] for any chemo receipt we would need the um the.
[AGENT][NEUTRAL] Explanation of benefits from your insurance carrier.
[CUSTOMER][NEUTRAL] OK, so I'm gonna have to go back through and because from what I can see in the, in the checks that, uh, you sent previously and the ones that I've just received.
[CUSTOMER][NEUTRAL] Out of 28 chemos, I think she's only been paid for 5.
[CUSTOMER][NEUTRAL] The rest of that was surgery, uh.
[CUSTOMER][NEUTRAL] Uh, another part of one of those checks was first time benefit user, uh.
[CUSTOMER][NEUTRAL] So I will uh.
[CUSTOMER][NEUTRAL] Before you process anything, I'm gonna try to go back to the doctor and have him resubmit.
[CUSTOMER][NEUTRAL] And, and anything that Medicare hadn't received or my supplement hadn't received, I will send you additional.
[CUSTOMER][NEGATIVE] Uh, I know some of the stuff that I sent you have been duplicated, but this is, this is really, really a pain to get.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] EOBs from the Medicare and then from the doctor. It's, uh, but, uh.
[CUSTOMER][NEUTRAL] Uh, if you would make a notation on her policy, I, I told uh [PII] a while ago that, uh, your name is what?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I have talked to a
[CUSTOMER][NEUTRAL] A [PII], a [PII], a [PII], and [PII].
[CUSTOMER][NEUTRAL] And then [PII], of course, and I've had to, I've had to remind them all, I said, I have an additional rider on this policy for $10,000 for cancer benefits.
[CUSTOMER][NEUTRAL] And it seems to go on deaf ears.
[CUSTOMER][NEUTRAL] So, uh
[CUSTOMER][NEUTRAL] I will, uh, I will try to get this straightened out. And here's, here's another thing that I would like to, uh, to address. Uh, I have sent.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I have sent the
[CUSTOMER][NEUTRAL] The physical address where we live in [PII], and I've sent the physical address.
[CUSTOMER][NEUTRAL] To uh
[CUSTOMER][NEUTRAL] Where we get her chemo when we go to [PII].
[CUSTOMER][NEGATIVE] And they say they won't pay for anything under 50 miles.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It is 62, it is 62 miles in a minute. I have, I've drove that road 11 years with a funeral, funeral home.
[CUSTOMER][NEUTRAL] And I've, I've drove to [PII], probably 500 times in the last 10 years.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] From our physical address, they said, well, GPS doesn't show that. Well, from my physical address to, to [PII].
[CUSTOMER][NEUTRAL] Uh, it's over 60 miles.
[CUSTOMER][NEUTRAL] And I've only been paid transportation.
[CUSTOMER][NEUTRAL] I think once or twice, maybe 3 times on, on anything. One of them was for the surgery, which is that at the hospital and the hospital is closer than what his office is.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, I have sent, I have sent receipts.
[CUSTOMER][POSITIVE] Uh, for, uh, and, and I hope that you, you still have those and can retain those. I've sent receipts for every time that she has done chemo.
[CUSTOMER][NEUTRAL] He does an in-house, uh.
[CUSTOMER][POSITIVE] Steroid and and a nodule. Every time that she received chemo, she got these, she's got these drugs to help her get through.
[CUSTOMER][NEUTRAL] Just the
[CUSTOMER][NEUTRAL] What it causes.
[CUSTOMER][NEUTRAL] And, uh, I'm wondering if any of those are gonna be paid for. Uh, I see outpatient drugs listed here on this one, on this one check.
[CUSTOMER][NEUTRAL] For, for $2.87 and $3.44. I'm, I'm wondering if they're paying on those and.
[CUSTOMER][NEUTRAL] I, I just, I just got some questions, uh, number one being.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] The, the $10,000 extra benefit, I'm gonna have to send you some more. I'm gonna have to send you some more stuff, evidently, because I'm only showing 4, maybe 5 chemos that they paid on out of [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] There was a
[AGENT][NEUTRAL] And that's in regards to [PII].
[CUSTOMER][NEUTRAL] And then the
[AGENT][NEUTRAL] Chemo received? Is that in regards to the chemo received in the calendar year of [PII]?
[CUSTOMER][NEUTRAL] Do you want, ma'am?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then, uh, for the physical address, the GPS, uh, you know, I've made.
[CUSTOMER][NEUTRAL] That's in [PII] alone, uh.
[CUSTOMER][NEGATIVE] We made 28 trips and that's not counting the times that we went over there hoping that she could get chemo that we had to turn around and come back because her numbers were too low.
[CUSTOMER][NEUTRAL] So, I mean, I've got 28 trips to [PII] for an expense for chemo. And, uh, I've only been paid for a couple of them and, and GPS, I don't know what GPS you're using, but physically from my house to his office, it over, is over 62 miles.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, I will get some more stuff sent to you and your name again was [PII], right?
[AGENT][POSITIVE] [PII]. Yes, that is correct.
[CUSTOMER][NEUTRAL] OK, are you in the office at [PII]?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, is there anything else you need from me?
[AGENT][NEUTRAL] No, I don't see anything additional needed at this time.
[CUSTOMER][NEUTRAL] OK, I'm looking at uh.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Here is on check number 202-9321.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Surgical benefits.
[CUSTOMER][NEUTRAL] Uh, remark number one.
[CUSTOMER][NEUTRAL] Are you, can you see this?
[AGENT][NEUTRAL] What do you have the claim number that, or do you know the payment amount of that check that you're referring to?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes ma'am, it's $3,023.47.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, uh,
[AGENT][NEUTRAL] OK, so I do have that information pulled up. Is that in regards to the surgery that was performed in in April or in December?
[CUSTOMER][NEUTRAL] In April, yes.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] That's the date that it's showing the, the [PII]. Yes. It says surgical benefit remark number one says, benefits are not payable for any disease other than cancer or one of the specified disease in the policy. What does that mean?
[AGENT][NEUTRAL] On that remark code for the surgery, it was a P1. That's not the same. I think you're looking at a different remark code. P1 is just this, the benefits were paid for that surgery, the P1.
[CUSTOMER][NEUTRAL] Well, I'm just, I'm just showing a one.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] The benefits are not paid for the disease other than cancer.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] Yeah, that's a D remark code. So that was in regards to the, to the surgery that was for 44955. Looks like the bill amount was for $203.
[AGENT][NEUTRAL] That remark code is, is in reference to that particular procedure.
[CUSTOMER][NEUTRAL] For $23.
[AGENT][NEUTRAL] The bill, the the charge amount goes for $203. That remark code is, is referenced to that particular procedure. The procedure code is 44955.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, I'll have.
[CUSTOMER][NEUTRAL] I'll have to find that one,
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] And according to what the policy states, uh.
[CUSTOMER][NEUTRAL] Surgical benefits, uh, on number 3 on remarks.
[CUSTOMER][NEUTRAL] Uh DE
[CUSTOMER][NEUTRAL] DIE
[CUSTOMER][NEUTRAL] Or D1E 6219.
[CUSTOMER][NEUTRAL] Uh, 2 or more surgical procedures performed through the same incision are considered one operation. Is that how you see that?
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] OK, so they only pay for the greatest, the greatest surgery procedure.
[AGENT][NEUTRAL] Yes, when 2 or more procedures are performed through the same incision.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, uh,
[CUSTOMER][POSITIVE] I will get some more. I will get some more stuff sent off and see if I can.
[CUSTOMER][NEUTRAL] Get get all this done and then
[CUSTOMER][NEGATIVE] The, the bad down, downside of this is that her cancer come back and we went through all of 24.
[CUSTOMER][NEUTRAL] Again and did this all again.
[CUSTOMER][NEUTRAL] No surgery, but, uh, the cancer had come back and, uh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'll, I'll address and send that stuff in at a later time when I get all the 23s taken care of, but if you would make that notation that there is a rider on this policy for the extra benefits.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] I definitely will get that noted on your account and inform that.
[CUSTOMER][NEUTRAL] OK, and then.
[CUSTOMER][NEUTRAL] And then take into consideration the uh the uh transportation cost, uh, of course I don't guess that you'll pay those unless you see an EOB for it, is that correct?
[AGENT][NEUTRAL] Yeah, well, transportation is only paid for the, those days that she, that she received chemo treatment.
[AGENT][NEUTRAL] And if it's within that, that allotted mileage for it and you say you, you submitted in the physical address to the facility, so I'll have that reviewed further as well.
[CUSTOMER][NEUTRAL] OK, well those
[CUSTOMER][NEUTRAL] Have, have them look at that again and, and the individual receipts that.
[CUSTOMER][NEUTRAL] His office worker filled out for us every time we went in. We paid out of pocket for those drugs that she received.
[CUSTOMER][NEUTRAL] Before he ever gave her chemo. It was an anti-nadule, a steroid. It was a, uh, what else was in there?
[CUSTOMER][NEUTRAL] Yeah, it was a steroid and anti-odule. Uh, it was a relaxer. It was a Benadryl.
[CUSTOMER][NEUTRAL] Uh, she received that every time, and I pay that out of pocket.
[CUSTOMER][POSITIVE] Uh, I will get some more stuff sent to you as soon as I can.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And, uh, if you would make a notation of that and, and, uh, at least check out the, the GPS if your GPS is correct.
[CUSTOMER][NEUTRAL] Yeah, we send a business card showing the physical address and our physical address to get from my house to the other side of [PII] where I live is 7 miles. I live on the north side of town.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] At the farthest point from [PII] that you can be in in Bor.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] I will, I appreciate your help. I will, I will get some more stuff in. Do we need to hang on to these checks? What should we do?
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] No, you can cash those checks. If there's any additional benefits payable, then you'll receive that additional funds.
[CUSTOMER][NEUTRAL] OK, yeah.
[CUSTOMER][NEUTRAL] Uh, there is one question.
[CUSTOMER][NEUTRAL] But uh uh OK, yeah.
[CUSTOMER][NEUTRAL] On [PII], uh, the check number.
[CUSTOMER][NEUTRAL] Of the amount of $112.66.
[CUSTOMER][NEUTRAL] It shows a, uh, anesthesia benefit.
[CUSTOMER][NEUTRAL] 365-556
[CUSTOMER][NEGATIVE] It doesn't give any remark or anything on that. It showed to pay $20.
[CUSTOMER][NEUTRAL] On anesthesia.
[AGENT][NEUTRAL] Yeah, I do show that that for [PII], yeah, $20.02 was paid for anesthesia and then we paid a surgery for that same day. It was $80.08.
[CUSTOMER][NEUTRAL] Surgical benefit, OK.
[AGENT][NEUTRAL] And the anesthesia was paid.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] OK, is that on the total?
[AGENT][NEUTRAL] Is there anything else I can assist you with today, Mr. [PII]?
[CUSTOMER][NEUTRAL] No, ma'am. I just, uh.
[CUSTOMER][NEUTRAL] I'll try to get all this redone again and, and.
[CUSTOMER][NEGATIVE] Send everything back, uh.
[CUSTOMER][NEUTRAL] I will go through and, and try to see, but I, I think from what I'm seeing and what we've seen and what's been sent back to us, we've only been paid for.
[CUSTOMER][NEUTRAL] 4, maybe 5 of the chemos out of 28 for the calendar year of [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright, well thank you very much.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. You have a good day.
[CUSTOMER][POSITIVE] You too thank you.
[AGENT][POSITIVE] Thank you. You're welcome. Bye.