AccountId: 011433970860
ContactId: 75b2cfa3-88a5-4a39-a724-a89d7acc1d39
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 707090 ms
Total Talk Time (AGENT): 191375 ms
Total Talk Time (CUSTOMER): 321587 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/19/75b2cfa3-88a5-4a39-a724-a89d7acc1d39_20250619T18:17_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling APO. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I seem to get you a lot. Um, this is [PII] over at the care team. I have a question. I have an insured on the line, policy number 727-573, and she said that she's taking a hormone, uh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] A hormone medication that's about, she said it's $23,000 a month. Um, and she's saying that she's taking it for immunotherapy for her, uh, cancer treatment, but they're only paying $75 or $50 for that, um, because it's a hormone, but she said it's for immunotherapy. She said someone from claims, and I, I checked through the notes a little bit, um, that someone is going to go back and check and see if it was still covered.
[CUSTOMER][NEUTRAL] And I was wondering if you had, if you could um um help me figure that out on what to tell her because it's a hormone, but it's as immunotherapy. Does she need a doctor's note saying that it's for immunotherapy?
[CUSTOMER][NEUTRAL] Because she said she's only getting $50 for it.
[AGENT][NEUTRAL] It would depend on
[CUSTOMER][NEUTRAL] But it's for the cancer treatment.
[AGENT][NEUTRAL] It would depend on what her benefits are. Give me one second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] April
[AGENT][NEUTRAL] from
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And she said that someone was supposed to give her a call back.
[CUSTOMER][NEUTRAL] Um, she said, she said someone named [PII] was going to give her a call back, um, to look into her past medical records. The only [PII] I saw because I'm new, was a secretary, so I, I don't think it was her. The last person I saw she looked at, which I'm, these notes don't always go to the very front for me, but the last person I saw she spoke with was [PII].
[CUSTOMER][NEUTRAL] I think is what it was.
[CUSTOMER][NEUTRAL] Where was that?
[AGENT][NEGATIVE] So it's gonna be Misty.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Misty, OK.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] And it's
[CUSTOMER][NEGATIVE] I don't understand why my notes when I first go to it, it takes me straight to [PII].
[CUSTOMER][NEGATIVE] And it's not showing me the most up to date.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That was back in March.
[AGENT][NEUTRAL] Give one second trying to pull up her policy.
[CUSTOMER][NEUTRAL] There we go.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, drugs and medicine benefit.
[AGENT][NEUTRAL] Uh, outpatient $50 per prescription up to $100 per month. One second.
[AGENT][NEUTRAL] OK, so, you know, therapy.
[AGENT][NEUTRAL] Uh, da da da.
[AGENT][NEUTRAL] So you know therapy benefit we'll pay the actual charges up to 15,000 for 12 month period. So it looks like the information she sent in last time. So is she, is she questioning what we paid the recent payment that we made, do you know?
[CUSTOMER][NEUTRAL] Uh, she's wondering why, yeah, she's wondering why she's only getting that hormone therapy benefit of $50.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And why it's not going towards her immunotherapy benefit.
[AGENT][NEUTRAL] OK. Uh, for hormone therapy.
[CUSTOMER][NEUTRAL] When she's taking it for immunotherapy.
[AGENT][NEUTRAL] Yeah, for the hormone therapy, it only pays up to $50 per treatment up to $12 per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Yeah, and that's, and that's what I told her, but then she said she's taking it as an immunotherapy and I, I didn't, I'm not versed well enough in this to know if
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] She would need like a doctor's note saying that it's for immunotherapy and not necessarily hormone therapy.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Uh, if it is immunotherapy, then we would need the, uh,
[AGENT][NEUTRAL] She's probably send in the explanation of benefits because we pay the actual charges so we would need the explanation of benefits.
[AGENT][NEUTRAL] So that we could see uh what the actual charges are but if you wanna send her over I can speak with her.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hi [PII], I have [PII] from claims and she's gonna help uh help guide you through that, OK?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Hi, good afternoon. This is [PII]. How are you?
[CUSTOMER][POSITIVE] I'm all right. How are you doing?
[AGENT][POSITIVE] I'm doing well thanks for asking.
[AGENT][NEUTRAL] OK. Uh, Ms. [PII], she said that you were stating that you had immunotherapy performed, is that correct?
[CUSTOMER][NEGATIVE] Yes, ma'am, the uh medication that they're giving me, uh, they said it was being used. It's called Orcido, the new one I took uh I took uh Ibras for almost 6 years and it stopped working and they started me on.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] One called True Cap, and it gave me a reaction. And so I got started on the Ordo and I send the claims in but only, they only pay $50 every time and I, and the medication costs $23,000 a month.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And if it's the hormone being, then why is it so high.
[AGENT][NEUTRAL] Uh, I don't know, uh, so I'm thinking that they must have looked this information up. Let me see if I have there's any notes in here.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And so I'm sure they looked it up to see what it was.
[CUSTOMER][NEGATIVE] Mm, someone named [PII] I talked to, I think that was her name, and she told me she was gonna go back through the claims and check it out and see what was what, but I never heard anything and then I just need to find out, you know, why is it costing so much if it's not what, you know, what I'm supposed to be uh getting it uh.
[CUSTOMER][NEUTRAL] Um, I've, I've, I've been taking it for ever since probably February or sometime, and when I send my claim in, every time I send it in, it says immunotherapy or it says on this thing I have it says immuno immunotherapy or or uh chemo radiation, 0.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And that's what's been on all of them, but it paid $50 on it, uh, for the last 2 or 3 months. I think it only paid $50 on it, but.
[AGENT][POSITIVE] Yes, ma'am, cause that's, that's the max.
[CUSTOMER][NEUTRAL] All the other times they paid me.
[AGENT][NEUTRAL] OK, cause the max benefit for for hormone drugs is $50 per treatment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So why are they uh charging so much? That's what I'm trying to find out if it's just a hormone.
[AGENT][NEUTRAL] That I would not know Ms. [PII]. I'm sorry, um, you would need to speak, speak with your doctor and see if it is um.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] If it is actually um an immunotherapy drug,
[AGENT][NEUTRAL] Uh, if it is, you could probably send us in something showing that, but if it is immunotherapy, we will, we pay that differently. So we would also need the explanation of benefits from your primary carrier so that we can see what the actual charges are.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. So all of that comes to my uh my cancer doctor is the one that has done all of the medication and stuff for me. I'm basically the uh the primary doctor just, you know, doesn't do very much with me now that I have the cancer. But uh uh you said you'll need an explanation of benefits of what?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes ma'am, who is your primary insurance carrier?
[CUSTOMER][NEUTRAL] Um, I have Humana.
[AGENT][NEUTRAL] Humana. So, uh, did Humana pay for these, for these drugs?
[AGENT][NEUTRAL] The drug that you're taking every month.
[CUSTOMER][NEUTRAL] They pay on some of the gift, but I have, yes ma'am. I have a co-pay now that they cut me off of Medicare, Medicaid.
[AGENT][NEUTRAL] Oh, OK, excuse me.
[AGENT][NEUTRAL] And so we would need the explanation of benefits that shows uh uh how much they paid because that's gonna have the actual charges on it because that's what we would need to see the actual charges for this drug uh and then you can also send us something uh from your doctor.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Uh, stating that is immunotherapy and then we can kinda research it from there to see, but I'm sure they looked it up to see whether it was immuno hormone, yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, I think.
[CUSTOMER][POSITIVE] Yes ma'am. Well, I thank you so.
[CUSTOMER][NEUTRAL] Yes, ma'am. Well, I thank you for your time and I'll get that, I'll get that done because I have the summary of uh the medicine that's why I was just wondering why it was costing so much because I got the summary from Humana and that one medication is $23,000 a month. And I take 30 pills. I get 30 pills and I take one a day.
[CUSTOMER][NEUTRAL] And, uh, and I get it, you know, once a month. And uh I, I send the uh the picture of the bottle and, and the information on it, but I will get the doctor when I go back to the doctor on the [PII], so it won't be until the [PII] before I can go to my doctor and see what's going on, but I will, I will get that. Thank you so much for your time.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, you're welcome.
[AGENT][POSITIVE] Have a great rest of your day, Ms. [PII].
[CUSTOMER][NEUTRAL] All right, bye-bye.