AccountId: 011433970860
ContactId: 7276d44f-b1a6-4697-aa85-82bb30195ec8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 882890 ms
Total Talk Time (AGENT): 335428 ms
Total Talk Time (CUSTOMER): 491771 ms
Interruptions: 1
Overall Sentiment: AGENT=1.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/7276d44f-b1a6-4697-aa85-82bb30195ec8_20250103T20:34_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] on the care team. How you doing?
[AGENT][POSITIVE] I'm good. How are you?
[CUSTOMER][NEUTRAL] I'm doing good. Um, I have an insured on the other line. Um, we've been on the phone for a little minute, but I just called their provider. They're sending in the UBO4 to her. Um, but there's two claims that she has questions about her transportation and surgery benefit, and I don't, I couldn't answer it.
[AGENT][NEUTRAL] OK, sure. What's the policy number?
[CUSTOMER][NEUTRAL] It's 242-858-9.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm. And it's um I'm sorry, claim number 3491561.
[CUSTOMER][NEUTRAL] And 1570.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] OK, hold up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 1570. OK, alright, you can send her over.
[CUSTOMER][NEUTRAL] Alright, thank you [PII], hold on one second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hello, [PII].
[CUSTOMER][POSITIVE] Yes, thank you so much for holding. I apologize for that wait. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] OK, thank you. You're very welcome.
[AGENT][NEUTRAL] Hi [PII], my name is [PII] in the claims department. How are you today?
[CUSTOMER][POSITIVE] I'm good. How are you?
[AGENT][POSITIVE] I'm good thank you. I understand you have some questions about a couple of claims.
[CUSTOMER][NEUTRAL] I do, please, if I could ask you those.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, what questions do you have?
[CUSTOMER][NEUTRAL] OK, so as I'm looking at some of the denial, um, it's, we're going back a few months because I've been on chemo and other treatments and I just haven't been able to call.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, but it's regarding these all center around surgery I had, and I live in [PII]. The surgery happened at MD Anderson Hospital, which is hundreds of miles away in [PII].
[CUSTOMER][NEUTRAL] Um, so naturally I had to travel down there and we took, um,
[CUSTOMER][NEUTRAL] We did an air flight which you covered um so there's a couple of things on these claims and I don't know if you want me to give you the claim number or just the dates.
[AGENT][NEUTRAL] The date will be fine.
[CUSTOMER][NEUTRAL] OK, so, um, we flew down on the [PII] because they had to do some various testing to make sure I was ready for um surgery such as blood tests to make sure all that was fine before I could be able to have surgery and so we stayed at a place called Rotary House.
[CUSTOMER][NEUTRAL] Um, because it's connected to the hospital there and they have it provided for the patients and
[CUSTOMER][NEUTRAL] Um, so I was there for several days. Um, my actual surgery was on, um,
[CUSTOMER][NEUTRAL] Um, [PII], and so of course I had to be there the night before because the surgery was very early in the morning and then I had to stay overnight and my husband was there and he was in the room and then I had to stay a few days afterwards because of the surgery. So all that I'm seeing with lodging is just one night, and I wanted to check about that and that was on the first claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, sure, and I do that here.
[CUSTOMER][NEUTRAL] I think
[CUSTOMER][NEUTRAL] Do that.
[AGENT][NEUTRAL] Um, and this is a verification of coverage. It doesn't guarantee the payment of a claim. The lodging for.
[AGENT][NEUTRAL] Let me get that date of service.
[AGENT][NEUTRAL] Was paid for.
[AGENT][NEUTRAL] On, I'm sorry, for date of service, [PII], which is the date of the actual surgery. Your lodging benefit, it only pays for dates um where you receive the covered treatment or procedure.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Unless it was an inpatient hospital stay.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It was an inpatient hospital day that night.
[CUSTOMER][NEUTRAL] Because I had the surgery on the [PII], and they kept me there at the hospital until the [PII].
[AGENT][NEUTRAL] OK. So in that case, we would need the itemized bill from the hospital.
[CUSTOMER][NEUTRAL] OK, and I feel like I've sent that in because the surgery benefit was paid.
[AGENT][NEUTRAL] Yeah, that's the surgeons. Sorry, go ahead.
[CUSTOMER][NEUTRAL] I don't have this.
[CUSTOMER][NEUTRAL] Oh, so is that not enough?
[AGENT][NEUTRAL] No, the surgeon's bill, it's uh separate from what the facility will provide. The facility typically doesn't have the surgery codes. So we specifically request the surgeon's bill when you're submitting for the surgical benefit. But we would still need the itemized bill from the facility to give us the um overall picture of that stay, uh, to show where it was considered inpatient and so on and so forth.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So those other dates that I was there recovering that really won't count. You're saying, so let's, let's just theoretically because I know they're gonna confirm it that I was overnight. So is the next night.
[CUSTOMER][NEUTRAL] Like I got out of the hospital there the morning of the [PII] sometime late in the morning. Um, that night, when I get lodging benefits for that?
[AGENT][NEUTRAL] The lodging benefit will be based on the information that's on the itemized bill. So if it shows that the hospital stay was for um one night, then that would only, the benefits will only be for that day. Um, but it's hard to tell it, it, it's hard to say over the phone without having that information in front of me to give a definite.
[CUSTOMER][NEUTRAL] In front of you, OK.
[AGENT][NEUTRAL] Um, but yeah, per the policy, the lodging is paid, um, during the days while you are hospital confined, and the lodging is paid for a family member or on the actual date that you receive the covered treatment or procedure.
[CUSTOMER][NEUTRAL] OK. So when I have surgery early that morning.
[CUSTOMER][NEUTRAL] Would y'all provide for the night before because I would need to be there since it's hundreds of miles away.
[AGENT][NEUTRAL] No, it would only be for the day that you received the service, yeah, and that benefit was paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, alright.
[CUSTOMER][NEUTRAL] OK, alright, so my second question is about the rental car. Do you cover any of that when you're out of town and you need the rental car to go back and forth between locations?
[AGENT][NEUTRAL] No, the rental car is not covered. Um, the transportation benefit covers the transportation mode in which to get you from your home address to the actual facility where the treatment will take place, um, but it does not cover rental car.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Um, because it's saying you needed verification that it was 50 miles away. OK, so the last question that I have is regarding, um, surgery benefit, and it, I get one of them was covered, but another was not. And what it told me when it had a number 4, it said send the pathology report.
[CUSTOMER][NEUTRAL] But I'd already sent one in.
[CUSTOMER][NEGATIVE] You know, that I do have cancer. I had the
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Invasive ductal carcinoma.
[CUSTOMER][NEUTRAL] Um, so I was confused about that.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] So the
[AGENT][NEUTRAL] Let's see this one. There was a surgery paid is this for the surgery on [PII]?
[CUSTOMER][NEUTRAL] OK, well, I, I'm confused because everything's that date, all the ones here. And so there's two different that say two different surgery benefits. I don't know. The first one, it's saying I have to have the pathology and then the second one was paid, so I don't really understand.
[AGENT][NEUTRAL] Mhm. OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So the surgery that was paid, that surgery code was for the mastectomy.
[AGENT][NEUTRAL] And that benefit was paid. There was also a surgery um code for the removal of lymph nodes. And we're asking for the pathology report from that to determine if that surgery, um, well, if that surgery code would be covered under your surgical benefit. If those lymph nodes were positive for cancer, then it'll be payable. If those lymph nodes were negative for cancer, then it will not be payable.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, well, they were negative, so it sounds like I don't even need to pursue that then.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Correct, yeah.
[CUSTOMER][NEUTRAL] OK, so that helps me. I don't wanna spend money on any time on something. OK, and the last question I have for you is I've started immunotherapy and that started the end of May.
[AGENT][NEUTRAL] Understood.
[CUSTOMER][NEUTRAL] And so I've had several treatments. I have them every 3 weeks. And the first one I received all of the information.
[CUSTOMER][NEUTRAL] I thought it was all that was needed, but in speaking with [PII], she had me talk with her to the um the facility and they're gonna send the UB40.
[CUSTOMER][NEUTRAL] Because I guess this isn't that, but I will say that on here, um, it's indicating that the cost for just my medication, which is translanidab I believe I'm saying that right, I may not be, but it's 43,000 for that one treatment.
[CUSTOMER][NEGATIVE] So I don't see any reason to send in more than the first one.
[CUSTOMER][NEUTRAL] Um, because she was saying we'll send all of them in, but.
[CUSTOMER][NEUTRAL] There really wouldn't be a need with there because my policy is up to 15,000.
[AGENT][NEUTRAL] Yeah, well, that will depend on.
[AGENT][NEUTRAL] The amounts paid by your primary insurance and anything that was out of pocket. Your policy pays actual charges, which is, um there's separate um columns on the explanation of benefits. There'll be the bill charges, which is what you're uh probably speaking of. Then there will be the amount that your primary insurance paid as well as anything applied to your co-pay, co-insurance or deductibles.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] This policy would pay those amounts, what your primary insurance provided plus any out of pocket. It doesn't pay the billed amount, so it's possible that that amount will max out your benefit, but again, I would not know that until we have the explanation of benefits.
[AGENT][NEUTRAL] But if you, if you look at the, go ahead.
[CUSTOMER][NEUTRAL] And I have that.
[CUSTOMER][NEUTRAL] Oh, I was just gonna say I have that.
[CUSTOMER][NEUTRAL] Here in front of me from Blue Cross Blue Shield.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And it's showing me.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Does it show in a loud amount?
[CUSTOMER][NEUTRAL] Fully, yeah, it's, it's just giving me a general overview I guess from insurance, but it's saying on [PII] that same day and then it gives the claim number.
[CUSTOMER][NEUTRAL] And it says they paid $83,850.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] So that they said fully paid.
[AGENT][NEUTRAL] On that explanation of benefits, does it have the date of service, the name of the drug, the amount billed, and the amount paid?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] It doesn't have the amount paid on there, but I have a separate document sent to me from insurance because I asked them to give me claim summary.
[CUSTOMER][NEGATIVE] That's what they would send to me, really difficult to get to send things like that, um.
[AGENT][NEUTRAL] Got it.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, but I felt like.
[AGENT][NEUTRAL] Yeah, well, you can send that over to I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] No, so I can just send all this right with what it says from the insurance.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And then what the covenant explanation of charges say because it.
[CUSTOMER][NEUTRAL] It lists everything but obviously we're just looking at that one.
[CUSTOMER][NEUTRAL] Charge for that actual immunotherapy.
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] Yeah, just send that over for a review and um if it maxes the benefit out then it'll be nothing else that you would have to send in and if it if it doesn't then you'll receive the correspondence showing that you still have a balance and you could submit for more.
[CUSTOMER][NEUTRAL] OK, so try that first one, we'll see what happens. Um, last thing, unfortunately because y'all have always been so good, um, in working with y'all, um, our, my school district is no longer using y'all APL, so I, my policy went through August I believe.
[AGENT][NEUTRAL] Yeah. Mhm.
[CUSTOMER][NEUTRAL] So, um, obviously nothing needs to be sent after that date, but do you happen to have that in your records? Do you tell me?
[CUSTOMER][NEUTRAL] Exactly when that
[CUSTOMER][NEGATIVE] Stopped
[AGENT][NEUTRAL] Yes, I showed the policy terminated [PII].
[CUSTOMER][NEUTRAL] OK, OK, yeah, I wasn't happy about that but anyway um so nothing after August needs to be sent, OK.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] But I had every 3 weeks from the end of May through the summer so I can submit those. OK. Oh, I think that's it.
[AGENT][POSITIVE] Alright, good deal. All right, so yep, you get that information over to us and we'll go ahead and um have those handled and processed for you.
[CUSTOMER][POSITIVE] OK, I appreciate your help.
[AGENT][POSITIVE] No problem. [PII], is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Not that I'm aware of.
[AGENT][POSITIVE] OK, good deal, feel free to give us a call back if you have any other questions.
[CUSTOMER][POSITIVE] OK, I will. Thank you very much.
[AGENT][POSITIVE] No problem thanks for calling APL have a great day.