AccountId: 011433970860
ContactId: 73e08dbf-1a41-4656-bd15-72bd5ad9f026
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 933400 ms
Total Talk Time (AGENT): 268934 ms
Total Talk Time (CUSTOMER): 366843 ms
Interruptions: 2
Overall Sentiment: AGENT=1.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/24/73e08dbf-1a41-4656-bd15-72bd5ad9f026_20250424T14:06_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. I'm calling to verify plan eligibility and benefit information.
[AGENT][NEUTRAL] Sure, I can check eligibility benefits for you. Um, what was your name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, [PII], can I get a good call back number from you first in case we're disconnected please?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] Um, it's
[CUSTOMER][NEUTRAL] I don't see a policy number on this um like letter that the patient brought in. I see a group, oh, is it a group policy number?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, we can see if that's right.
[CUSTOMER][NEUTRAL] It's 24842.
[AGENT][NEUTRAL] OK, no that's not gonna be the policy number, but that might be their actual group number um give me just a moment. What was the name for the number?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Is that [PII]?
[CUSTOMER][NEUTRAL] Yes. And his first name [PII], he spells it um [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Got it. OK, one moment, let me try to look within the group.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Do you know if the primary might be um a spouse or?
[AGENT][NEUTRAL] Something like that.
[CUSTOMER][NEUTRAL] Let me see what, uh, what this is.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I believe so because it says it's through.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I see 2 members in this group with that last name, uh, neither are his, but I can, I can just go ahead and check both.
[CUSTOMER][NEUTRAL] OK, it's just that um his employer is different than who the group is, so I'm thinking then the group would be the, maybe his spouse's employer, but I'm trying to find her name and I'm not.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] No, no, that's OK. Um, do you have [PII]'s date of birth?
[CUSTOMER][NEUTRAL] Sure, where they would put that.
[CUSTOMER][NEUTRAL] Uh-huh, yeah, it's [PII].
[AGENT][POSITIVE] Cool, I did find him um so give me just a moment let me get to the right.
[AGENT][NEUTRAL] Policy. Oh well, maybe not, um.
[AGENT][NEUTRAL] So the only uh policy I found that's under it is under his spouse um but that is uh it's a cancer policy was this supposed to be for um medical or dental?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um, it's for medical. He has skin cancer, so he's coming, um, he's needing like an excision.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK, so this is a cancer policy. Um, let me see. Give me just a moment. I'm going to see if
[AGENT][NEUTRAL] He might have another one on his own. I'm gonna see if I can't find his social and search for him that way. Give me just a moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, no, I'm not finding any others, um.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] He does, so this, he has a primary insurance and then he's also brought this in and wants us to have it.
[CUSTOMER][NEUTRAL] But I don't know what it would cover. I know it says it's like a limited benefit for.
[CUSTOMER][NEUTRAL] Uh, specified disease cancer insurance policy, but I, it doesn't give me any details on what the benefit is.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] I see. OK, so then this must be what he was trying to give you. OK. Alrighty. Give me just a moment. Let me go ahead and get that policy pulled up. Um, I'm sorry, what did you say he was actually going to be being seen for?
[CUSTOMER][NEUTRAL] So it's, so it's outpatient hospital surgery that we would be billing and it's um
[CUSTOMER][NEUTRAL] Oh gosh. I'm, I'm looking at codes. So it's an excision of a lesion in a pretty big area.
[AGENT][MIXED] OK, but it was for.
[CUSTOMER][NEUTRAL] But we're it's outpatient hospital surgery.
[AGENT][NEUTRAL] OK, but it was for his, you did say he does have cancer, and that's what this is for?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Right, it's to treat melanoma of the skin, a malignant melanoma cancer.
[AGENT][NEUTRAL] OK. OK. Well, let me check first because all of our cancer policies are quite different. Some do not cover skin cancer. It's only going to be internal. So let me check that first.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I don't see that specifically as an exclusion.
[AGENT][NEUTRAL] So let me see what his benefits are now.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] I appreciate your patience. I'm sorry, I'm just sifting through the, uh, all of the, um, policy.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][POSITIVE] OK. I do see a surgical benefit.
[AGENT][NEUTRAL] OK, um, here is what I'm going to do, [PII], um, I'm going to put you on a brief hold if that's all right with you. Um, I'm going to reach out to our claim specialist just so they can give me some clarification. So we do, it's a surgery to remove, um.
[AGENT][POSITIVE] Exactly what was it? I'm sorry.
[CUSTOMER][NEUTRAL] Let me see. So,
[CUSTOMER][NEUTRAL] It's an excision um of a malignant lesion.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Um, what's this other one? Let me see what this other one is.
[CUSTOMER][NEUTRAL] 11,430.
[CUSTOMER][NEUTRAL] Looks like a tissue transfer.
[CUSTOMER][NEUTRAL] Probably over the area where it's gonna be exposed.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] OK, I appreciate you clarifying that a bit more just so I have specifics um OK give me just a moment I'm just gonna put you on a brief hold I'll reach out to them and I'll get right back with you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[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], it's [PII] on the care team. How's it going today?
[CUSTOMER][POSITIVE] It's going pretty good. How are you, [PII]?
[AGENT][POSITIVE] So far so good. Thanks. So I've got a provider on the line, uh, who's calling about a, uh, cancer patient, um, and their cancer policy. Um, I can give you that policy number. In short, he has, um, skin cancer, which I don't see as an exclusion on this one. And he's having a surgery to remove a malignant lesion and a tissue transfer.
[AGENT][NEUTRAL] I see the surgical benefit writer, but I don't see anything specific regarding that. So I wasn't sure what to tell her.
[CUSTOMER][NEUTRAL] So she's needing to know like what needs to be submitted?
[AGENT][NEUTRAL] No, um, just if that would be um a benefit, uh, payable benefit under this policy.
[CUSTOMER][NEUTRAL] Oh, got you, got you, OK, yeah, what's that policy number?
[AGENT][NEUTRAL] It's 253-233-0.
[CUSTOMER][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] Like usually I feel like under the
[AGENT][NEUTRAL] The surgical benefit writers, it would kind of give more specifics, but I don't see that.
[CUSTOMER][NEUTRAL] So under the surgical benefit writer um it is based off of the code that they use um that is how we pay so.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The list if there is one, isn't going to necessarily um provide all of the benefits that we.
[CUSTOMER][NEUTRAL] Would pay it's just going to kind of mention like sometimes you know it has like different surgeries that are coverable and how it's covered um for this one specifically.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It just says um that we provide.
[CUSTOMER][NEUTRAL] That the benefits we provide for this loss are incurred by the covered person is under the rider following a diagnosis of cancer or skin cancer and for treatment of cancer or skin cancer, and it just says a charge must be incurred. So the way that it's determined is based off of the code.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so in short, it would most likely be covered, but you know I'll just give disclaimer and that's pretty much that.
[CUSTOMER][NEUTRAL] Yeah, um.
[CUSTOMER][NEUTRAL] You don't have to go into it but just kind of this information for you so when it says unit dollar amount is $30 so we go by relative value which is a screen that we look at to look up the CPT codes and that's kind of the units that we're looking at so you know if they were to have um.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] A surgery like that has 17 units, then what the system does is it takes that those units and multiplies it by their dollar amount to determine the payable amount.
[AGENT][NEUTRAL] Oh,
[AGENT][MIXED] Interesting, OK, but it's, uh, it wouldn't exceed that 3000.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] Right, it's, it's not going to exceed the 3000 and if there's more than one on um on a day or through I think it's through the same procedure let's see um let's see.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, we will pay the lesser. That's not it. OK, 2 or more surgical procedures performed through the same incision, so they're considered one operation. So when they take the tissue from the other location.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That may be considered because it's like if they were to take it from their stomach or their thigh or their back, which are pretty common areas because of how much surface area there is and let's right, that is probably something that we would cover because let's say they're putting it on their face or their hand or something like that. It's a different incision so they're removing it here and they're replacing it here, but the removal of the.
[AGENT][NEUTRAL] Yeah, the excess. Mhm.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Malignant cancer and then the tissue on top would likely just be considered one because it's all one area. So that's the only difference there. It's possible that not every procedure this day will be covered, but
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um, we will consider it because skin cancer treatment, surgical procedures are covered under this benefit.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] That's interesting. I swear I love talking to you. You just always, it's so informative um really, I'm so you're so good. um, well, if you wouldn't mind, could you explain that to her?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Oh, I love it.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] I really appreciate it. I just don't wanna, I feel like I understand, but I don't want to say something wrong. Um, her name is uh [PII].
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][POSITIVE] [PII], OK, yeah, I'll be happy to.
[AGENT][NEUTRAL] Yes, and this is for, uh, part two is for [PII].
[CUSTOMER][NEUTRAL] Part two, OK.
[AGENT][POSITIVE] Yes, I appreciate your help. Thank you so much, [PII].
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][POSITIVE] No problem, you're welcome, care.
[AGENT][NEUTRAL] All right, bye.
[CUSTOMER][NEUTRAL] Bye bye.