AccountId: 011433970860
ContactId: 79c4d286-8f0b-4485-9e16-4e5cede5c1e2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1600869 ms
Total Talk Time (AGENT): 150278 ms
Total Talk Time (CUSTOMER): 363048 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=-1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/06/79c4d286-8f0b-4485-9e16-4e5cede5c1e2_20250306T21:39_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] how are you?
[AGENT][POSITIVE] I'm doing good how are you, [PII]?
[CUSTOMER][POSITIVE] I have a, I'm doing good. Um.
[CUSTOMER][NEUTRAL] I have an insured on the phone regarding policy number 252.
[CUSTOMER][NEUTRAL] 7441.
[AGENT][NEUTRAL] 252-744-1, OK.
[CUSTOMER][NEUTRAL] The claim is for part two [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And it's regarding the claim that was processed today, uh, the 357-2318.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm not understanding the line one that denial reason that DHO 42.
[AGENT][NEUTRAL] Uh let me see what it says.
[CUSTOMER][NEGATIVE] It might be the wrong code.
[AGENT][NEUTRAL] 2 year pre we do not cover pre-existing conditions for the 1st 2 years that the coverage becomes effective.
[CUSTOMER][NEUTRAL] Wonder if that was supposed to be 242 for lab.
[AGENT][NEUTRAL] Possibly um you can send her on over and I'll contact the um.
[CUSTOMER][NEUTRAL] OK. OK. OK. All [PII], thank you, and this is Mrs?
[AGENT][NEUTRAL] The examiner to see.
[CUSTOMER][NEUTRAL] On the phone it's it's [PII] mhm.
[AGENT][NEUTRAL] Mrs. [PII].
[AGENT][POSITIVE] OK alright thank you.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Alright.
[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] I was calling to check on the claim that I have put in, and the lady I was speaking to stated that you guys denied it because it said that you do not pay for a pre-existing condition within two terms of the.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Within 2 years of the of the policy, but you just, I just filed a claim claim 2 weeks ago and you paid it. So now why all of a sudden you're canceling the pay the the um policies claiming pre pre.
[CUSTOMER][NEUTRAL] Precondition. Why, why is that all of, yeah, why is that now all of a sudden?
[AGENT][NEUTRAL] Preexisting, yes ma'am.
[AGENT][NEUTRAL] Uh, it looked like that may have been an error.
[CUSTOMER][NEUTRAL] I just feel like ever since we've been on this doggone policy this year, I've got nothing but a hard time. All the years previous ain't never been any issues until now.
[CUSTOMER][NEGATIVE] The minute I confirmed that after 16 I can file a claim, you all have been denying it every time I see one in. It's, it's like I have to go above and beyond more than what I've ever had to do before. Then when I want to know why everything is different, I don't get an explanation, and now you're telling me I paid for a policy that you all won't even now all of a sudden won't pay, but you just paid it.
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] Uh, um, give me one second. As I stated, I think this probably was, uh, the incorrect remark code was used, but let me double check that for you.
[CUSTOMER][NEGATIVE] I bet it wasn't. I don't wanna pay out the claim no more.
[AGENT][NEUTRAL] No, I don't think that's the case. One second.
[CUSTOMER][NEUTRAL] I would love my husband to not have cancer anymore. I would enjoy it. I would be ecstatic. But for y'all to do this and making it more difficult every time I call, that is what that lady put in. I'm almost sure of it.
[CUSTOMER][NEGATIVE] Cause it's always been something negative every time I call, every time I put in a claim, it's a problem, it gets denied, you won't pay it. Every time since I was told to start putting in my claims after [PII].
[AGENT][NEUTRAL] As I stated, give me one second, I'm checking to see if that was the incorrect remark code that was used. One moment please.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] Come on, that's this shit.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, Ms. [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, thank you for holding. OK, as I stated, she used the incorrect remark code and that was for the lab work and so this policy does not cover lab work, so she's gonna go back and change that remark code. So once you receive the EOB it should have the correct remark code on it.
[CUSTOMER][NEUTRAL] I sent the ELB with that.
[AGENT][NEUTRAL] No ma'am, when you receive the EOB from for from us that tells you uh what we did with your claim.
[AGENT][NEGATIVE] That remark code should be correct. It should not state that preexisting it's not covered.
[CUSTOMER][NEUTRAL] So what is it being declined for?
[AGENT][NEUTRAL] Uh, the lab work that he had done on [PII].
[AGENT][NEUTRAL] The
[CUSTOMER][NEGATIVE] I know you don't pay for that. You pay for the, you pay for the chemo drugs.
[AGENT][NEUTRAL] OK. Uh, so.
[CUSTOMER][NEGATIVE] I, I can't get them to separate all of that. It's all on the one itemized bill.
[CUSTOMER][NEUTRAL] Cause he gets labs first, then he gets chemo, so it's all on one itemized bill. His chemo is on there, the chemo is also on the ELB from the insurance.
[AGENT][NEUTRAL] OK. All right. So, uh, as far as the chemo goes, it said that the radiation, uh, therapy, chemotherapy does not, the, the benefit does not cover the other procedures related to the chemo. So, um, they won't give you anything that breaks it down.
[CUSTOMER][NEUTRAL] What procedure?
[CUSTOMER][NEUTRAL] I gave the itemized bill from the doctor. It's the same itemized bill from the last from the last claim.
[CUSTOMER][NEUTRAL] It's the same as that hospital, same as that chemo, same as that everything, the, the blood work is always on there. I know you don't pay for labs, but the chemo drug that you do supposed to pay for is on the itemized bill.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] It says online 12345678 HC chemo ADM IV $1163. Then two lines down, chemo extended infusion with pump, no whatever, you probably don't pay for the pump, fine, whatever. Then at the top it says IV therapy ad. It's on the itemized bill. So what are we talking about?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It has the code over there too that you guys request. So like I say, you deny it just to deny it.
[CUSTOMER][NEUTRAL] Is the handle.
[CUSTOMER][NEUTRAL] If you look at the one that you paid the 866, the itemized bill, it goes down. I chemo, IADM IV one hour infusion there, it's it's the same exact itemized bill with different dates with the same drug.
[AGENT][NEUTRAL] Give me 1 2nd to pull that information up to compare 1 2nd.
[CUSTOMER][NEUTRAL] Uh, going.
[CUSTOMER][NEUTRAL] I'm following the insurance company. I'm gonna follow with the insurance company.
[CUSTOMER][NEGATIVE] Cause they could continue to deny a claim and I always give me no.
[CUSTOMER][NEUTRAL] It's insurance.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] One second, I'm comparing what we paid last time and what we did not pay this time.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] right
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] One second, she's reviewing it.
[AGENT][NEUTRAL] And see, see if she maybe if she missed it. One second.
[AGENT][NEUTRAL] Because I do see that we have paid on those codes in the past.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I said that that was.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEGATIVE] Why? Do I hear y'all in back that doesn't have a serious.
[CUSTOMER][NEUTRAL] Keep where you're supposed to be, please. Hello.
[AGENT][NEUTRAL] Yes ma'am, still here.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] I'm still waiting to hear back from.
[CUSTOMER][NEUTRAL] Hey baby, I'm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Hello. Let's go.
[CUSTOMER][NEUTRAL] She said you I.
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] That I was gone, didn't you?
[CUSTOMER][NEUTRAL] You need to go to ISS. need to go to ISS. Get back upstairs by her door and stay there till she opens it. I don't want to hear it back upstairs. OK, she can be blue and purple for all I care, get up there by the door and stay there.
[CUSTOMER][NEUTRAL] You 3
[CUSTOMER][NEUTRAL] Go to [PII] and get all of that paint stuff.
[CUSTOMER][NEUTRAL] And put it
[CUSTOMER][NEUTRAL] On that table where you see I put a little tray.
[CUSTOMER][NEUTRAL] It should be. Go ahead. I'll stand right here and check.
[CUSTOMER][NEUTRAL] This is
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Did we get the other boxes that's closed too? Mhm. Everything that's on the table. Put on the table with, well, like I said, when you see the paint in those trays, please. Thank you.
[CUSTOMER][NEUTRAL] Mr. [PII], Miss [PII], I need a student from [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The of [PII].
[CUSTOMER][NEUTRAL] He's name now.
[CUSTOMER][NEUTRAL] [PII], I need [PII].
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEGATIVE] No but you can't be out tomorrow. We're not done with this stuff.
[AGENT][NEUTRAL] OK, Ms. [PII], she said that she is gonna reprocess the claim. Do you have a telephone number that I can call you back once it's done?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, that's [PII].
[CUSTOMER][POSITIVE] That's correct.
[AGENT][NEUTRAL] OK, alright, as soon as she finishes with this claim, I'll give you a call back.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Alright, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Bye bye.