AccountId: 011433970860
ContactId: 7653c67d-d7cc-4022-a2eb-b47c25fc3f74
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 646559 ms
Total Talk Time (AGENT): 247394 ms
Total Talk Time (CUSTOMER): 306488 ms
Interruptions: 11
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/17/7653c67d-d7cc-4022-a2eb-b47c25fc3f74_20250617T17:11_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] Hey [PII], my name is [PII].
[CUSTOMER][NEUTRAL] And my claim number is
[CUSTOMER][NEUTRAL] 361-175-6
[AGENT][NEUTRAL] And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII] is where I'm calling from.
[AGENT][NEUTRAL] Thank you. And I have your policy here. I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] 11558. 11558.
[CUSTOMER][NEUTRAL] The email is [PII].
[AGENT][NEUTRAL] And the mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you for that. And how may I assist you today?
[CUSTOMER][NEUTRAL] Uh, I'm showing I got a text that the claim was completed and I'm looking online and it's showing amount paid or of 27,580.
[CUSTOMER][NEUTRAL] And is that coming to me by check or was in the mail or was that direct deposited?
[AGENT][NEUTRAL] Uh, let me check for you. Hold on one moment.
[AGENT][NEUTRAL] Um, so that'll be a check in the mail. I'm not showing direct deposit has been, um, elected yet.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, in the mail is great uh my next question, it's telling me.
[CUSTOMER][NEUTRAL] Remarks
[CUSTOMER][NEUTRAL] The radiation does not cover the procedures, anything.
[CUSTOMER][NEUTRAL] And that would have been
[CUSTOMER][NEUTRAL] I don't know. I guess are they not considering my full vestrate?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] So all the
[CUSTOMER][NEUTRAL] As a cancer treatment because it, it is.
[AGENT][NEUTRAL] So all this is saying is the policy itself will only cover the treatment, so like the chemotherapy, radiation, immunotherapy, that other code down there that was, that was denied, it's, it's for like, how can I explain it? It's for like delivery of the of the the medicine.
[CUSTOMER][NEUTRAL] No, the drug itself was 48, almost $5000.
[AGENT][NEUTRAL] Not the drug itself, I said delivery. So this was, this was denied for radiation delivery. So if you go to the second page of your explanation of benefits.
[AGENT][NEUTRAL] It kind of breaks it down. So it's not, it's not saying the medicine itself, it's saying the delivery, how it's administered.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] So that's why that code was denied, but the treatment was covered.
[CUSTOMER][NEUTRAL] The I.
[CUSTOMER][NEUTRAL] OK, I'm confused.
[AGENT][NEUTRAL] Alright, so it reads the radiation.
[CUSTOMER][NEUTRAL] I thought it was the medicine.
[CUSTOMER][NEUTRAL] See these were shots. It's a, the medicine is for veri and it's a shot in each hip.
[CUSTOMER][NEGATIVE] Administering the shot was $290 which I understand that's not covered.
[CUSTOMER][NEUTRAL] The medicine itself was almost $5000.
[AGENT][NEUTRAL] So on the second page of your explanation of benefits, where it's because the reason I'm saying that is because it's a big old, like it's a block to read. That's what it's explaining it's not covered.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Right, um, it's like 5 lines.
[AGENT][NEGATIVE] Right, so it's not saying that your medicine nor the treatment, it's not saying that. It's saying the delivery, how it got to where you got it done was not covered. The code that they gave was not covered, but the $275.80 that they charged for chemotherapy was paid in full.
[CUSTOMER][NEUTRAL] OK, I'll have to pull my EOB because they charged me $290 for administering it.
[CUSTOMER][NEUTRAL] Because see I have 3 codes on the EOB on my thing there's a.
[CUSTOMER][NEUTRAL] The diagnosis code, of course, and the and the encounter for anti neoplastic chemotherapy.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Mhm. So for that they
[CUSTOMER][NEUTRAL] I guess that's where I'm confused because I got checks last year for my therapy up to my $20,000 limit.
[AGENT][NEUTRAL] Right, so you're confusing to, you're
[CUSTOMER][NEUTRAL] I'll have to go back and look at some of those.
[AGENT][NEUTRAL] What you're speaking of the $20,000 limit and the $275.80 that we paid, that's a part of that limit. So it has been paid. What
[CUSTOMER][NEUTRAL] Right, right, I was expecting.
[CUSTOMER][NEUTRAL] Both of these, the 290 and the 4880.
[CUSTOMER][NEUTRAL] To be paid, so that's what I'm.
[AGENT][NEUTRAL] It sounds like you might have a diff.
[AGENT][NEUTRAL] It sounds like you might have a different.
[CUSTOMER][NEUTRAL] That's where I'm confused.
[CUSTOMER][NEGATIVE] Because even my EOB that I submitted to y'all because you I did I failed to submit the EOB with my.
[CUSTOMER][NEUTRAL] Detailed.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Ledger of what was charged.
[CUSTOMER][NEUTRAL] Even has the therapy.
[CUSTOMER][NEUTRAL] The therapy was 290.
[CUSTOMER][NEUTRAL] The drugs, which was the medicine itself was 4880, so that's where I'm getting confused.
[AGENT][NEGATIVE] Well, the 4880 is not what was billed to us. The, there was only $275.80 that was billed to us for chemotherapy and we paid that in full. The only thing that was not covered was the delivery of the radiation, which is not, it's not the treatment, it's not the medicine, it's just, it could be medical supplies.
[CUSTOMER][NEUTRAL] OK, well if you'll look on my.
[CUSTOMER][NEUTRAL] OK, this is
[CUSTOMER][NEGATIVE] So confusing if you'll look on my initial claim submission.
[CUSTOMER][NEUTRAL] Uh, we just submitted it, let me think.
[CUSTOMER][NEUTRAL] OK, my initial claim I submitted.
[CUSTOMER][NEUTRAL] was on [PII], I received a confirmation number of OSC 98311.
[CUSTOMER][NEUTRAL] And that ledger has
[CUSTOMER][NEUTRAL] Two items on it, the $290 and the medicine itself for $4880. So I don't know who, who, who at APL received it or processed it, but those two items are on what I submitted on this ledger.
[AGENT][NEUTRAL] Would you like to speak to someone in claims from because I don't, other than what's here, I don't have further information for you in terms of why it's different.
[CUSTOMER][NEUTRAL] That would be.
[CUSTOMER][POSITIVE] That would be great.
[CUSTOMER][POSITIVE] OK, that would be great.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much for your help.
[AGENT][NEUTRAL] Alright.
[AGENT][NEUTRAL] You're welcome, [PII]. Was there anything else I can assist you with before I transfer you?
[CUSTOMER][NEUTRAL] That's it for now.
[AGENT][NEUTRAL] All right. Well, thanks for calling APL. Hold on one moment while I get an examiner on the line for you, OK?
[CUSTOMER][POSITIVE] Yes, ma'am. Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I think
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Good morning. Thanks for calling ATL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you doing?
[CUSTOMER][NEUTRAL] On the new
[AGENT][NEUTRAL] I'm doing good. Um, I have a um insured on the other line. She, we were going over a claim, um, she, well, let me give you the policy number first.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, it's 257-952-2.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's um
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] Hold on.
[CUSTOMER][NEUTRAL] The one in the 1756.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, I was trying to pull up my notes. OK, so we went over it. I went over the denied um part and the the radiation delivery is not covered.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] She's saying from what she received on her or what she sent in.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, on like the ledger.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] The dollar amounts differ from what was sent in from what we paid.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It has nothing to do with what was what it was denied for, but that's what she, she wants to talk to somebody about like in on base when I pull up her claim on the ledger it does show two different prices than the $275 that we paid, but
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] That that
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] I think she's trying to loop that in with why it was denied and I'm trying to explain to her, but that the charge was 27,580 and that's what we paid, but
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] So she wants to get more information.
[CUSTOMER][NEUTRAL] I know.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEUTRAL] Send her on over.
[AGENT][NEUTRAL] OK, thank you. Hold on one second.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] OK, thank you so much. Appreciate you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. I'm sorry, good afternoon. Thanks for calling.