AccountId: 011433970860
ContactId: 6197c458-9f5e-4b84-9e03-3711591d5214
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1143800 ms
Total Talk Time (AGENT): 480466 ms
Total Talk Time (CUSTOMER): 582943 ms
Interruptions: 4
Overall Sentiment: AGENT=0.9, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/25/6197c458-9f5e-4b84-9e03-3711591d5214_20250425T15:19_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] Hi [PII], I am calling because I have a claim um that I had sent in and I got a letter from the claims department, uh, that it's being reviewed but they needed additional information to proceed, um, based on my recent effective date of coverage, it's necessary to obtain medical records to determine if your claim is due to a preexisting condition, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It in the claimant I, I have this through my husband and it says to complete this uh former current healthcare providers on section A and B. My husband didn't have a so.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm trying to think. So his, my husband was diagnosed with cancer in [PII] of this year.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And we, the only uh the only thing I had was this little supplemental cancer policy from APL through my, through my school and it wants me to, we did, he didn't get established, he didn't have a primary physician. The very first day he saw a primary physician was [PII] because we went to the emergency room, that's where they discovered the cancer. So then we had to get established with the primary physician.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And it's wanting this to uh they want former or current health providers to fill this.
[CUSTOMER][NEUTRAL] Um, thing out but he didn't have a former healthcare provider.
[AGENT][NEUTRAL] So, um, I follow you. So let me do this first. Let me pull up the policy.
[CUSTOMER][NEUTRAL] Does that make sense?
[AGENT][NEUTRAL] Um, look at, look at the, you know, you're fine. Look at the dates and then, um, just in general.
[CUSTOMER][POSITIVE] Oh, I'm so sorry.
[AGENT][NEUTRAL] If there, we're asking for that because by law, if the policy is less than a year old, we have to see if it's pre-existing, so that's just everybody. But if y'all don't have like a provider, then um all you can do is submit what you have. So who is that first doctor that he saw and if you can get, well, let me not get ahead of myself. Let me, let me, let me see what what was all asked for first and then I can go into specifics for you.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Well, 1st may I have your name?
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] And my middle initial is [PII] and last name is [PII] and I'm the insured.
[AGENT][NEUTRAL] OK. And [PII], may I have a good contact number in case we're disconnected and then your policy number?
[CUSTOMER][NEUTRAL] Sure, the contact number is [PII].
[CUSTOMER][NEUTRAL] The policy number is 02549154.
[AGENT][POSITIVE] Thank you. Hold on.
[CUSTOMER][NEUTRAL] And I also have a
[AGENT][NEUTRAL] Oh, go ahead, I can hear you still.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh, I've got a reference number and a claim number. I don't know if you need that as well.
[AGENT][NEUTRAL] OK, and [PII], can you verify your date of birth, your mailing and email address on file?
[CUSTOMER][NEUTRAL] Sure, my date of birth is [PII]. Uh, mailing address is [PII]. Email address is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So do you mind if I place you on just a brief hold? I'm just gonna look through the claims and see what I was asked for and then I'll be able to direct you more clearly.
[CUSTOMER][NEUTRAL] OK, that's fine.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Alright, so this is a dupe of the other ones, yes, OK.
[AGENT][NEUTRAL] Wait a minute.
[AGENT][NEUTRAL] They were paid.
[AGENT][NEUTRAL] Oh wait, there's some more codes. Wait a minute. Oh, wait a minute. E 2200.
[AGENT][NEUTRAL] Yeah, hold da da da da da. OK, so that's what she's talking about. So we got pre-X.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] What's this one DE.
[AGENT][NEUTRAL] 0123 inpatient services are not covered under this policy, OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hm
[AGENT][NEUTRAL] Just to be sure.
[AGENT][POSITIVE] I'm gonna make sure.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Calling APL, this is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you doing?
[CUSTOMER][POSITIVE] Good. How about you?
[AGENT][POSITIVE] I'm doing good. Um, can, OK, so I have a general question, but I have the policy number too if you need it.
[AGENT][NEUTRAL] You want me.
[CUSTOMER][NEUTRAL] OK, what's the policy number?
[AGENT][NEUTRAL] So it's 254-915-4.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it's for part two.
[AGENT][NEGATIVE] Um, we paid out on the claim, but some of the codes were denied. One of them was denied for um pre-existing and asking for the, what is it, like the list of physicians.
[AGENT][NEUTRAL] That they're seeing
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But they're saying he doesn't, he didn't have a list, uh, he doesn't have a list of physicians because he went to the emergency room and that's where they found the cancer and then the emergency room told them that he needs to set up primary care. So do I tell her to just send what records they have, I mean just put what doctors.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I guess so at the ER.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And the primary care that he set up? OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes. Mhm.
[AGENT][NEUTRAL] OK, I just want to make sure before I said it.
[CUSTOMER][NEUTRAL] Yeah, yeah, so we would just need that information.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All right. Well, thank you. Have a good day.
[CUSTOMER][POSITIVE] You too. You're welcome.
[AGENT][NEUTRAL] All right, bye bye.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] All right, thank you so much for holding. I apologize for that wait. Um, I also called over the claims just to make sure um what I'm getting ready to tell you was correct. So, yeah, they said all you need to do is submit um the whoever the treating doctor was at the ER and whoever the doctor is that you all have established care with for primary care because that's all he, you know, has for now.
[CUSTOMER][NEUTRAL] OK, but the primary care he didn't have prior to [PII].
[CUSTOMER][NEUTRAL] Before the I mean, he didn't get the primary care until after he's been diagnosed. My claim is.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Before.
[CUSTOMER][NEUTRAL] It's before he was diagnosed.
[CUSTOMER][NEUTRAL] Does that make sense?
[AGENT][NEUTRAL] Wait a minute, the claim
[CUSTOMER][NEUTRAL] Because now he has.
[CUSTOMER][NEUTRAL] He currently has insurance that he was effective [PII]. So that's why we have, he, that's why he has a primary care physician. Prior to [PII] of this year, which all this transpired in January of this year of [PII] [PII], I took him to the emergency room.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's where they discovered he was like, they couldn't treat him, they sent us on to [PII].
[CUSTOMER][NEUTRAL] So he had no primary care doctor at that point. All we saw was whoever was in the emergency room here in [PII]. I'm not sure where you're at, but here in our local town, they sent us on. So my claim, because he was diagnosed with cancer, that the policy that I had just gotten at school that went into effect [PII] of this year.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Because that's when I signed up for it was [PII] the [PII].
[CUSTOMER][NEUTRAL] Of [PII] of this new school year.
[CUSTOMER][NEUTRAL] My claim is because in [PII] is when he was diagnosed. He had no primary care physician prior to any of this.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So when you're asking me to fill out a healthcare former, a former and current healthcare providers,
[CUSTOMER][NEGATIVE] He has one now, but that's, this, it negates because it, I'm not asking y'all to cover anything prior, uh, I mean, after [PII], because after [PII], he has insurance that is picked up.
[CUSTOMER][NEUTRAL] The majority of like his medical bills. I'm asking for the claim to cover prior to not having any coverage. We had no insurance other than this APL.
[CUSTOMER][NEUTRAL] So he didn't have a, he did not have a prior.
[CUSTOMER][NEUTRAL] Healthcare provider.
[AGENT][NEUTRAL] Right, so you just won't have anything for prior. You'll just put that all you have is
[CUSTOMER][NEUTRAL] So then I just
[AGENT][NEUTRAL] Is the emergency room.
[CUSTOMER][NEUTRAL] So I just signed this paper.
[AGENT][NEGATIVE] No, no, no.
[CUSTOMER][NEUTRAL] It says signature.
[AGENT][NEUTRAL] So I asked the claims examiner how you would handle this, and I told her that you, that he didn't have any doctors prior um to the claim. He just, he went to the emergency room and they sent or they advised y'all to then establish care with the primary care.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And I said, so does she just send in the emergency room and primary in the primary care that he has now, you know, the name, and she said, yes, so that's all you have. So if you just won't have any prior.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] But I, well, the prior is the emergency room doctor, whom I don't even know because that's just they have people that come and fill in. It's not like a regular person. So how am I gonna, I guess what I'm trying to say is how, I don't, how am I gonna get that person's, it's got a PCP first name primary, I can fill out, I guess, the primary care provider, but it doesn't even tell like when he started. I mean,
[AGENT][NEUTRAL] So that's not, that's not. So what you're, what you're trying to figure out is not needed. So they're just trying, so whether he, let me get my words together, whether he was with them prior or not, that's who treated him. So that's why we need the name. If you have a discharge summary, the doctor's name from the ER is on there, um.
[CUSTOMER][NEUTRAL] On this form of
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What else would the doctor's name be on?
[CUSTOMER][NEUTRAL] But then does he have to fill, oh, you see, it's got that on this form that you're asking me to fill out, it's got section A, primary care provider, physician, a PCP. He didn't have one. But section B says other healthcare providers, which I guess that's where I would put.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Whoever treated him at the emergency room.
[CUSTOMER][NEUTRAL] Whoever had treated it at that time.
[AGENT][NEUTRAL] Right, and then for PCP you would just put whoever you all established care with and they're gonna request records and all they can provide is what they have and that that's all we need.
[CUSTOMER][NEUTRAL] OK, well, I
[AGENT][NEUTRAL] Because he didn't have care prior to the emergency room visit.
[CUSTOMER][NEUTRAL] Right, but he's not
[CUSTOMER][NEUTRAL] No, but I mean he but our primary has records now.
[CUSTOMER][NEUTRAL] That's what I'm not understanding why I have to list our primary.
[AGENT][NEUTRAL] Right, so what
[AGENT][NEUTRAL] Because the emergency room referred you to the primary. So even though the records will be after
[CUSTOMER][NEUTRAL] I'm
[CUSTOMER][NEGATIVE] No, no, no, the, no, the emergency room did not.
[CUSTOMER][NEGATIVE] They did not uh refer us to get a pre. We went to the emergency room. He had cancer. We were in the hospital 7 days. After we got out, they were like, look, you, you need to get insurance.
[CUSTOMER][NEUTRAL] I called the number I got insurance.
[CUSTOMER][NEUTRAL] The, uh, the emergency room did not tell us to go to a primary care physician.
[CUSTOMER][NEUTRAL] The hospital was like, look, he's gonna have to have insurance. Here's this lady's number. Give her a call. She can set you up with insurance.
[CUSTOMER][NEUTRAL] That's how I got set up with a primary doctor.
[CUSTOMER][NEUTRAL] You know, weeks later, after he'd been in the hospital for 7 days.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It wasn't like the emergency room went and said go get a primary because that's not what happened.
[AGENT][NEUTRAL] So either way, all we, all we're needing is whoever has treated him. So he is now treated by the primary care, put that down, and he was treated at the emergency room where the cancer was found, put that doctor down. They're then going to ask or could possibly ask for records, even though he didn't have the primary care at the time of the emergency room, the diagnosis from the emergency room matches the care that's given at primary. It, it all goes together.
[AGENT][NEUTRAL] So I
[AGENT][NEUTRAL] It doesn't matter if he went to primary care 1st, 1st, we just need who saw him.
[CUSTOMER][NEUTRAL] OK, if you like.
[CUSTOMER][NEUTRAL] And you also need the current primary care physician.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] OK, just, you are making this, and I know it's not you, but you're making this so difficult. It may, and this is why people don't take these policies out because you, it's up to you to file instead of, you know, when you do get regular insurance. It's a very frustrating process. They make it sound so easy at school to go, oh look, here, get this cancer policy. It's super easy. That way if you're ever diagnosed, they'll be able to cover some things.
[CUSTOMER][NEGATIVE] That is so not the case, to be perfectly honest. Because when you're going through what we're going through, trying to get all this crap is secondary. And I'm sorry to be blunt, but I'm just frustrated that it's just um trying to get y'all to help cover just cause we owe so much money for everything.
[AGENT][POSITIVE] Correct, yes. No, I understand. This is, this is a life change.
[CUSTOMER][NEUTRAL] You know, and we've provided, you know, we send everything and now y'all just keep kind of, oh now we need this, and here's this, and here's this, and here's this. It makes it like, is it really worth just taking this, my time away from what I need to be focusing on to make sure that y'all have everything that y'all need. And that's why I'm a little frustrated and I'm, I apologize and it's not your fault.
[CUSTOMER][NEGATIVE] But I will try to get this in and I'll try to do it, but I mean I feel like it's like you are stonewalling. Oh here, let's just, now you need this if you want us to help pay for some of this, you know, and I, I'm just frustrated, so I'm sorry.
[AGENT][POSITIVE] And I understand your frustration and you're totally valid in feeling how you feel. This is your life just changed like that, that's major. So I, I understand exactly how you're feeling, but you have to breathe and know that you're doing all you can do. Now for the policy, to be honest, let me ask you this, does the, does the um
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEGATIVE] The hospital and the primary care, did they have this policy number because to be honest, you're not supposed to be doing this. They're supposed to be filing all this for you. So that's another part um that I want to take off for you.
[CUSTOMER][NEUTRAL] No, I'm
[CUSTOMER][NEUTRAL] No, they, I mean, that was the whole thing is with this you have to solve it yourself. I mean like.
[AGENT][NEUTRAL] Oh, so they said.
[CUSTOMER][NEUTRAL] I mean, that's what I unders.
[CUSTOMER][NEUTRAL] That's what I understand from school.
[AGENT][NEUTRAL] So
[AGENT][NEGATIVE] So they advised you wrong.
[CUSTOMER][NEUTRAL] Is that that this is
[AGENT][NEUTRAL] So listen,
[AGENT][NEUTRAL] This is all you have to do moving forward. This one was the first one, they told you the wrong thing to do, but moving forward, anything that he has or even you, if it's a wellness claim, what, you know, memo, anything, give the doctor's office your policy number and our phone number to call and verify benefits.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Once they have our policy number, they're gonna bill, you know, if you have other insurance, they'll bill that and then they'll bill us automatically. So you do not have to do all of this. Now, on your policy, hold on, let me see before I say it just to make sure. On your policy, you do have a first occurrence benefit. If there is ever a positive diagnosis, it'll pay out um depending on the type of uh cancer, up to 75.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Mm.
[CUSTOMER][NEUTRAL] Which, which.
[CUSTOMER][NEUTRAL] Mhm, which is what this is. It was a first time diagnosis when we went in January.
[AGENT][NEUTRAL] Right, so that what I was gonna say is that's the only time I advise my patients to file on their own because that 7500 comes straight to you. But everything else, let the doctor do it because you have enough stress, just trying to.
[CUSTOMER][NEUTRAL] Oh, I
[CUSTOMER][NEUTRAL] Right, right.
[AGENT][NEUTRAL] Do the day to day on your own.
[CUSTOMER][NEUTRAL] I know, yeah, so yeah, you're preaching to the choir at this point, so, OK, well I will go back.
[AGENT][POSITIVE] So that might help alleviate a little bit.
[CUSTOMER][NEUTRAL] It will, it will, it's just trying to get this 1st 7500 and do it correctly.
[AGENT][NEUTRAL] Yes, so after this, give them that policy number, so and and say bill my insurance and don't worry about it and let them handle it.
[CUSTOMER][NEUTRAL] You know, because.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well I'll get this filled out and I'll go back and get the emergency room stuff and try to get all this filled out and get this turned in.
[AGENT][POSITIVE] Yes, ma'am, and all you and be, be patient with yourself and give yourself some grace because this is a lot on you.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It is, it's, it's a lot, so it's a lot.
[AGENT][NEUTRAL] But you got it and and APL got you too. So if you need anything, just give us a call and we'll help you through it, you know, forms or whatever, but we have to ask for these things because if we get audited, it's a whole big mess if there's something missing and we paid it out, you know, just legalities.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right, right.
[CUSTOMER][POSITIVE] OK, well I'm gonna search through my records and get what y'all need and then I'll get it turned in so I appreciate it.
[AGENT][POSITIVE] You're very welcome, [PII]. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Uh, no, ma'am, that's it, so.
[AGENT][POSITIVE] All right. Well, thank you for calling APL and I hope you have a good weekend.
[CUSTOMER][POSITIVE] Thank you. You too. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye bye.