AccountId: 011433970860
ContactId: 65367a21-c87f-434e-a633-b1482e2d7c0b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1317770 ms
Total Talk Time (AGENT): 462522 ms
Total Talk Time (CUSTOMER): 678819 ms
Interruptions: 8
Overall Sentiment: AGENT=0.5, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/25/65367a21-c87f-434e-a633-b1482e2d7c0b_20250425T20:02_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Um, yes, I have a question. I have, um, was checking a claim status online and it shows that it was completed today, um, but it says amount paid 0, so I was looking to see why it's being apparently not paid.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, OK, I can um give you an accurate claim status. There, you can't really go by that because everything goes to the, well, tomorrow is the weekend, but everything goes to the bank at [PII], so that's why, um, everything is kind of generic right now, but I can check for you just to make sure.
[CUSTOMER][NEUTRAL] Oh, OK, maybe that's why it won't let me. OK, all right, maybe.
[CUSTOMER][NEUTRAL] Maybe that's why the hyperlink for the claim number isn't working. I was trying to look at. I know sometimes like if they need additional information though, OK, we have, can I give you the what, what do you need from me, my social or the claim number?
[AGENT][NEUTRAL] Oh, yes.
[AGENT][NEUTRAL] Well, 1st may I have your name and a good contact number in case we disconnected?
[CUSTOMER][NEUTRAL] Mhm. Sure. um I'm [PII] and my best phone number is um [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Thank you for that. And may I have your policy number?
[CUSTOMER][NEGATIVE] Mm, yes, it is no.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK, you have the member number.
[CUSTOMER][NEUTRAL] Probably somewhere here on my.
[CUSTOMER][NEUTRAL] Can I give you my social? Sorry, I thought I had, I'm logged in. I just don't see where it's at.
[AGENT][POSITIVE] Oh, yes, that's fine. That's no problem.
[CUSTOMER][NEUTRAL] OK, uh, my social is [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So I'm just waiting for the policy to come up here.
[AGENT][NEUTRAL] OK, here we go. It just popped up. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And this is for, looks like this is a cancer policy?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, this is it. Hold on one second.
[AGENT][NEUTRAL] All right, and I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] Sure, my date of birth is [PII], and my um email address is [PII] and my mailing address is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And so
[AGENT][NEUTRAL] So is this for, hold on one moment. Let me do it this way.
[CUSTOMER][NEUTRAL] Yeah, we put it in no
[AGENT][NEUTRAL] Is this for you or your spouse or dependents?
[CUSTOMER][NEUTRAL] My spouse.
[AGENT][NEUTRAL] OK, because I was under you and I'm like, I don't see anything since last year. OK, that makes sense. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] OK, let me see. Do you mind if I place you on just a brief hold while I look at this um claim?
[CUSTOMER][NEUTRAL] Sure, go ahead.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, thank you so much for holding. I apologize for that wait. It was almost as if there were two claims, but it was really, one was a duplicate. So, I do see that the claim finished processing, um, it's on direct deposit and it's a total of $20,791.20.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, can you give me that one more time? Sorry, 27, uh huh.
[AGENT][NEUTRAL] Sure. $20,791.20.
[CUSTOMER][NEUTRAL] 27, sorry, I don't know why I'm having trouble writing that figure. sorry 220791, right?
[AGENT][NEUTRAL] Mhm. Yes, ma'am.
[CUSTOMER][NEUTRAL] And how many cents? 20?
[AGENT][NEUTRAL] 20.
[CUSTOMER][NEUTRAL] OK, OK, I don't know why it's been a long day. OK, alright, um, I guess.
[AGENT][NEUTRAL] It's, it's almost the end, end of the day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I know it it's been a long week. OK, alright, and um.
[CUSTOMER][NEUTRAL] OK, and will I get, I don't even remember what all I had submitted to be paid out because I know like different things pay out. Are you able to tell me what all, what all they paid for because I just went ahead and just submitted a whole bunch of invoices and let you guys sort it out.
[AGENT][NEUTRAL] Mhm. Um, so it looks like.
[AGENT][NEUTRAL] The, so there were two charges of, um, that were both at 10,000 and then the daily hospital benefit, um,
[CUSTOMER][NEUTRAL] I know the cancer chemo.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see, that's a total of $700.
[AGENT][NEUTRAL] And then where's the 91?
[AGENT][NEUTRAL] Oh, here it is. Transportation. Um, there's two transportation charges, well, payments of $45.60 which brings the $91.20.
[CUSTOMER][NEUTRAL] OK, and then
[CUSTOMER][NEUTRAL] So then I have a question. Maybe I didn't submit the right thing. I think he also gets, we also get like a payout if he gets like a trans a blood product like transfusion, and I thought I had submitted that. I wonder if they need something additional.
[AGENT][NEUTRAL] Oh, that must be this. Hold on one second. Let me see what this means.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] No, that's for transportation.
[AGENT][NEUTRAL] There's a few transportation. When you get your explanation of benefits, um, pay attention to the second page, only because it's a breakdown of like each code and then what was paid and if it's denied what it's asking for, because like some of these transportation um charges are asking for the physical address. So once we get it, they'll they'll continue processing um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then let me see.
[CUSTOMER][NEUTRAL] OK, and there should be another one I had there was a invoice I submitted from the [PII] residence in because um I think it covers like hotel while he's in the hospital and he was in there so I submitted that invoice. Do they need something more for that?
[AGENT][NEUTRAL] When he
[AGENT][NEGATIVE] So, no, that one was actually denied. So when he was in the hospital, was he receiving like radiation, chemo or immunotherapy or he was like
[AGENT][NEUTRAL] It was just like an office visit or was he receiving treatment?
[CUSTOMER][NEUTRAL] He was receiving treatment. He had what is called a CAT therapy, and you have to stay, it's a requirement to stay within 30 minutes of the hospital for 30 days. So, um, part of that we were, he was in the hospital and then, but then, and then I was at the hotel and then he joined me at the hotel for the other half of it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So he had a pro a procedure. It's called CAT. It's like a it's basically like a cell, um transplant, basically it's it's a it's basically like a transplant. They harvest your own cells, re-engineer them and put them back in you, but you do have it is a requirement to stay within so far the hospital for 30 days, and we lived outside that range, so we had to stay in a hotel.
[AGENT][NEUTRAL] OK, so for that one.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] So that's what that is, the Marriott, mhm.
[AGENT][NEUTRAL] I, I have two options.
[AGENT][NEUTRAL] I can either
[AGENT][NEUTRAL] Get a claims representative on the line, see if a claim support representative is um available to speak with you now, or I can send a message over to them to have them research the claim and reprocess if they need to because it's coming back as um no treatment, uh, how can I say it, because there was no treatment received, so therefore the transportation isn't covered, but if they need to revisit this and see that there was treatment.
[AGENT][NEUTRAL] Um, I don't know if you wanted to talk to one of them. I'll be more than happy to get a rep or I can send it over. Well, I think you should maybe talk to them because sending it over if they see the same thing.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And still, you know what I mean, still, it still doesn't make sense and they still might give the same decision. I'm just trying to see how to avoid, you know, I just, I don't know if they know that that that is a
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, but you can let them know and I don't know if I've submitted. I don't know if they might need me to submit additional. I can't remember if I've submitted anything for.
[CUSTOMER][NEUTRAL] When he was in the hospital that week or that month was a you know what I mean?
[AGENT][NEUTRAL] I think you should talk to a rep.
[AGENT][NEUTRAL] Yeah, so that you can get a straight answer now versus and because if they reprocess, yeah, that's not gonna make any sense. I think you should talk to somebody and then that way they can understand what, what, you know, he received and then let you know next steps like what, what would be needed in that case.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, but before we get a representative on the line, was there anything else that I can assist you with today?
[CUSTOMER][NEUTRAL] No, that's everything.
[AGENT][NEUTRAL] OK, [PII], well, thank you so much for calling APL and um hold on one moment while I get a claims.
[CUSTOMER][NEUTRAL] Oh, what, yeah, when will I receive that payment that originally called about the [PII]?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] It looks like it just finished processing today and everything goes out to the banks um at [PII] and your direct deposit. So I just don't know because tomorrow is Saturday, like how the banks, you know, would work.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh, I understand, yeah.
[CUSTOMER][NEUTRAL] Yeah, probably within the next few days, so yeah, that's OK, yeah, I was just making sure I didn't need to do anything else before getting that, OK.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] Um, so hold on one moment, I'm going to get a rep for you, but thank you so much for calling APL and I hope you have a good weekend.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you you too thank you for all your help.
[AGENT][NEUTRAL] Thank you. You're welcome. Hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][POSITIVE] Hey [PII], this is, oh my gosh, I'm so happy I got you. Hey [PII], it's [PII]. How are you doing? Now that I've seen your face and I put it all together, I'm like, [PII].
[CUSTOMER][POSITIVE] Hey, I'm good. How are you?
[CUSTOMER][NEUTRAL] How are you, ma'am?
[AGENT][POSITIVE] I'm doing good. Um, OK, so I have policy number 736951.
[CUSTOMER][POSITIVE] Good.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, it's claim.
[AGENT][NEUTRAL] Claim number 3588117 is for part two.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, OK, so there's 2 charges on here 2 lines on here for FM.
[AGENT][NEUTRAL] Trans A.
[AGENT][NEUTRAL] Um, it's for residents in, so the codes were denied, but saying that there was no treatment received, so he couldn't, so they, we couldn't pay out for the transportation, or I'm sorry, for the, the lodging. So,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, she's saying, but it was treatment done, it was some type of like cellular treatment, and he had to stay in the hospital for 30 days and while he was in the hospital, she was at the hotel and then he came and joined her, but he, she said he did receive treatment and wanted to speak to a rep to see what she can do to or submit to like show us that that he was in treatment.
[AGENT][NEUTRAL] But I didn't know how to answer that.
[CUSTOMER][NEUTRAL] Uh, give me just a second. Yeah, no, that's fine.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So,
[CUSTOMER][POSITIVE] Just love it man.
[CUSTOMER][NEUTRAL] P I BFT is fake love it.
[CUSTOMER][NEUTRAL] OK, I'm trying to look at the policy to see. I'm pretty sure it's family transportation and lodging.
[CUSTOMER][NEUTRAL] Is what that stands for like family member?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, I'm pretty sure that's what that is, and let me look, so we did not.
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Did she give you a date that he was in the hospital for this?
[AGENT][NEUTRAL] No, um, she, but she did mention it was 30 days he had to stay in the hospital because they like took his cells out and then did something to him and put him back in his body. Like, she explained the whole thing. I'm like, I really, I'm not really the person to give all this to.
[AGENT][NEUTRAL] But I was, but I was listening though.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Well, I hear you. I don't know what you're talking about, but I hear you.
[CUSTOMER][NEUTRAL] OK, because I have put in every date between [PII] and [PII], and we don't have any record. Oh shoot, I was on part I was on part one. OK, let me try this again. [PII]. So where to go, [PII], pay attention. OK, [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It's OK, it's almost the end of the day.
[CUSTOMER][NEGATIVE] Not for me, girl, I don't leave till [PII].
[AGENT][POSITIVE] Oh, I'm sorry.
[CUSTOMER][POSITIVE] Ah, I appreciate it.
[CUSTOMER][NEUTRAL] Oh
[AGENT][POSITIVE] I'll be with you in spirit.
[CUSTOMER][NEUTRAL] OK, so so far I appreciate that, um, OK, so I've almost done this again except for under the correct participant and we don't have anything that shows he was in the hospital or anything like.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] All I see.
[CUSTOMER][NEUTRAL] Is that one line and then.
[CUSTOMER][NEUTRAL] For [PII] through [PII]/13, was that the same like procedure is that like the next?
[AGENT][NEUTRAL] I think that's like the next set and she said.
[CUSTOMER][NEUTRAL] Like, was that part of the same, the OK, part of the same 30 days because it looks like [PII]13 through [PII] so it's probably part of the same because I bet it's limited. Mhm. OK, so uh.
[AGENT][NEUTRAL] That's the same.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Because she said he um
[AGENT][NEUTRAL] Oh yeah, it's the same. He stayed in there and then he came in.
[AGENT][NEUTRAL] Um, stayed with her for the last 30, for the last half of it, I mean.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Yeah, I've put in all of those dates now I do have.
[CUSTOMER][NEUTRAL] The only thing I have that includes [PII]3 is where it looks like there was maybe office visits, um, and the office visits are not covered, so but I don't have anything for November.
[CUSTOMER][NEUTRAL] Like I don't, I'm trying to see if there's anything that may be hiding in here.
[CUSTOMER][NEUTRAL] So [PII]. I have a hospital stay from [PII] to early [PII]ry of 25.
[CUSTOMER][NEUTRAL] And then the only other thing we have before November is March like we don't have anything showing so what we're gonna need is we're gonna need to see that I mean I can still look at um.
[CUSTOMER][NEUTRAL] I can look at what was submitted to, but.
[CUSTOMER][NEUTRAL] Um, what was this? 8117.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Unless we have proof of treatment because it's not payable unless we have paid.
[CUSTOMER][NEUTRAL] Because of treatment or hospital stay or you know whatever the case may be, however the policy reads and so with that's why it was denied because what it's stating.
[CUSTOMER][NEUTRAL] You know, um,
[CUSTOMER][NEUTRAL] Is specifically that treatment's not been received, so it says it's payable when a covered person who has been diagnosed is having cancer received, receives covered radiation, chemo, immuno, bone marrow or stem cell transplant or surgery in a hospital that is at least 50 miles from their home. Um, on your recent claim, it appears there was no covered treatment received therefore, transportation and lodging is not covered for the state. Please refer to your policy contract.
[CUSTOMER][NEUTRAL] So it's because we don't have any record of anything for those dates. All we have based off of just looking at this is that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] They were, they had some lodging and it's like OK that's fine but we don't have any record of anything else.
[AGENT][NEUTRAL] Treatment to go with it. So she needs to send like the itemized bill and, well, really, that's everything.
[CUSTOMER][NEUTRAL] Rock.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Anything
[CUSTOMER][NEUTRAL] Yeah, I would tell her that based off of the documentation that we've received, which I'm looking, I'm trying to look through that now it's 27 pages, but based off of what we have, we don't have, well, there's 12:13 right there.
[CUSTOMER][NEUTRAL] Oh, it's nuclear medicine and imaging. That's not treatment.
[CUSTOMER][NEUTRAL] Let me check that CPD code.
[AGENT][NEUTRAL] So she needs to send in the um itemized bill for [PII] through the 30th and then for well for both of them.
[CUSTOMER][NEUTRAL] Yeah, for both of them she needs to send in the itemized bill for the treatment received because just.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just looking at it, um,
[AGENT][NEUTRAL] It just looks like they went to the hotel.
[CUSTOMER][NEUTRAL] Uh-huh, it just looks like they went to the hotel. Now I do see where it looks like there was like some type of IV therapy or treatment or whatever the last part of December, but that doesn't cover the lodging and if he was staying with her during that time, then.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You know that makes sense that we wouldn't be paying for this. It has to be those dates and all I have are the 28th and twenty-ninth, um where he was there maybe overnight or something, you know.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, I'm trying to get through this because I know you need to get back over to them.
[CUSTOMER][NEUTRAL] Uh, yeah, there's 12:31316. He was in the hospital.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, let's see what this because there we have several bills but.
[CUSTOMER][NEUTRAL] I looked in the history and I don't see anything and then.
[CUSTOMER][NEUTRAL] 124 so that's early or late January and then.
[CUSTOMER][NEUTRAL] We have this bill for room and board.
[CUSTOMER][NEUTRAL] At the hotel and it's like, OK, none of this matches up with the bills that we have that's why we need proof of treatment so itemization for the treatment received is what we're gonna need to be able to go back and reconsider this.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so like the UBO4.
[CUSTOMER][NEUTRAL] Yes, um, and yeah, I would say that and I would say if she has, you know what, just tell her to send that in because if we need anything else, I don't even know what all we would need. I'd have to go looking and figuring out with this particular policy, what it requires. I would just say we need proof of treatment.
[AGENT][NEUTRAL] It was the hospital.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So hospital bill, whatever it is that she has for proof of treatment during that 11:13 through 12/13 where where they have that hotel bill we need that.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK. All righty, well, thank you.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][POSITIVE] All right, have a good weekend.
[CUSTOMER][NEUTRAL] You too.
[AGENT][NEUTRAL] Bye bye.