AccountId: 011433970860
ContactId: 810a4e59-5947-4c46-9eaf-21d33a70931f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1125969 ms
Total Talk Time (AGENT): 619471 ms
Total Talk Time (CUSTOMER): 251872 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/23/810a4e59-5947-4c46-9eaf-21d33a70931f_20250423T19:51_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh, yes, I'm calling about some claims that I had filed and seeing what else is needed. I think maybe there's some missing stuff.
[AGENT][POSITIVE] OK, well, I can definitely help you with your claims. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Alright, [PII] Great House and my number is [PII].
[AGENT][NEUTRAL] Thank you. May I have your policy number?
[CUSTOMER][NEUTRAL] Um, there's several of them. I, I have several different.
[CUSTOMER][NEUTRAL] Oh, policy number, you know what? Hold on, let me.
[AGENT][POSITIVE] Take your time.
[CUSTOMER][NEUTRAL] And it's uh my policy is the same under my name regardless, right?
[AGENT][NEUTRAL] Well, if you have multiple policies, I'll, I just need one and then I'll be able to see the others, but
[CUSTOMER][NEUTRAL] Cause I have more than one claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me, I'm finding it.
[AGENT][POSITIVE] Mhm, take your time.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I think.
[CUSTOMER][NEUTRAL] I found it. My number is 252.
[CUSTOMER][NEUTRAL] 854 7
[AGENT][NEUTRAL] OK, thank you. Hold on one moment.
[AGENT][NEUTRAL] And can you verify your date of birth, your mailing and email address on file?
[CUSTOMER][NEUTRAL] Uh, [PII] and the address is [PII].
[CUSTOMER][NEUTRAL] And my email is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So hold on one moment.
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold? So there's several lines, so I'm gonna see what they were denied for, but then there was $150 that was paid, but I'll see what these other reasons are and what needed.
[CUSTOMER][NEUTRAL] Yeah, because the one I'm trying to figure out because I they just now paid me for my, I think the surgery for my thyroid, I had thyroid cancer last year and then this year I have, I had breast cancer.
[CUSTOMER][NEUTRAL] So I got paid. they looks like they're gonna pay 12,000 and I think that was for the thyroid it looks like um surgeries and stuff at the hospital.
[CUSTOMER][NEUTRAL] But um, I don't, I want to clarify that. And then if so, do we, do they have everything for the most recent, which would have been the, um the, the breast cancer surgery.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hm, OK, so,
[AGENT][NEUTRAL] There's several, the only way that we can kind of narrow it down is the dates of service, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Because there are several lines here, but they grouped it all under one claim number, which is the 358-5913.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] That's, it was, they were all received on [PII].
[CUSTOMER][NEUTRAL] I'm looking.
[CUSTOMER][NEUTRAL] Probably, mhm. The date of the surgery would have been [PII] if that helps.
[AGENT][NEUTRAL] Looks like we and then.
[AGENT][NEUTRAL] [PII], that I think I did see that date. Hold on one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, so I have
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], OK, so [PII] of this year, [PII] of last year, [PII].
[AGENT][NEUTRAL] [PII] of last year.
[AGENT][NEUTRAL] Do I see any other dates? [PII] of this year.
[CUSTOMER][NEUTRAL] I think
[CUSTOMER][NEUTRAL] I, I wanna say I feel like maybe they already paid everything that they're gonna pay for the last year's one.
[CUSTOMER][NEUTRAL] But this year's I think is the one that I'm not sure if they have everything for which would have been the January and the March because it was a different cancer.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And a new year.
[AGENT][NEUTRAL] So just look for the ones from [PII].
[CUSTOMER][NEUTRAL] I think so like at least I can clarify, work on that first and if there's anything else I'll go from there.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I'm just gonna place you on a brief hold and go through the claim and look through all the dates of service for [PII] and the denial reasons to see what's needed.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] You're welcome. Hold on one moment, OK?
[CUSTOMER][POSITIVE] OK, no problem.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Alright, so let me start, 00, so first the current she's not going to get because that's once per lifetime. So let's
[AGENT][NEUTRAL] That might be the 12,000 she's talking about.
[AGENT][NEUTRAL] And let me pull up her policy.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] All right, so, and I'm sure that is that what that code says. Let's see DE.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] But it's OK, [PII]. Hold on one second.
[AGENT][NEUTRAL] And I'm gonna come right here, is that what she was saying the lump sum.
[AGENT][NEUTRAL] She said 12,000, OK, it's 10.
[AGENT][NEUTRAL] OK, so 33 1st current form per LT.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What else was 25.
[AGENT][NEUTRAL] Then she also has oops, she also has 33 2020.
[AGENT][NEUTRAL] Surgery.
[AGENT][NEUTRAL] Anesthesia.
[AGENT][NEUTRAL] Uh, labs, offices, OK, well, let's do this first.
[AGENT][NEUTRAL] That one was DE.
[AGENT][NEUTRAL] 0249.
[AGENT][NEUTRAL] UBO4.
[AGENT][NEUTRAL] I mean, it's the same thing.
[AGENT][NEUTRAL] Uh surgery bill.
[AGENT][NEUTRAL] C T N D X.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, what's the next one anesthesia DE.
[AGENT][NEUTRAL] Please send the surgery charge. So once you do that, that'll take care of both of them.
[AGENT][NEUTRAL] What else is 2025?
[AGENT][NEUTRAL] OK, oh.
[AGENT][NEUTRAL] 12
[AGENT][NEUTRAL] 24.
[AGENT][NEUTRAL] 3325 labs. What does that say? DE.
[AGENT][NEUTRAL] 0242.
[AGENT][NEUTRAL] Uh it's not covered. Anything else 25.
[AGENT][NEUTRAL] Office visit 1:17.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 2125 DE.
[AGENT][NEUTRAL] Our offices is not covered, but let me make sure.
[AGENT][NEUTRAL] Yep.
[AGENT][NEUTRAL] And then anything else?
[AGENT][NEUTRAL] I'll just put.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Wait, I did that wrong. [PII].
[AGENT][NEUTRAL] Maria Genetics.
[AGENT][NEUTRAL] DE 051.
[AGENT][NEUTRAL] No
[AGENT][NEUTRAL] Covered by policy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] The is.
[AGENT][NEUTRAL] Calendar year Max Max for.
[AGENT][NEUTRAL] I see that 2 12 [PII].
[AGENT][NEUTRAL] And then we paid 33 2025.
[AGENT][NEUTRAL] What is that?
[AGENT][POSITIVE] Oh wait, oh wow.
[AGENT][NEUTRAL] Oh man.
[AGENT][NEUTRAL] Come on.
[AGENT][POSITIVE] Mastectomy daily hospital benefit. That's exactly what it is.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] $50.02 days we paid $100. There it is. Oh, OK.
[AGENT][NEUTRAL] The daily hospital benefit, we paid $100 for 2 days.
[AGENT][NEUTRAL] 150 per day.
[AGENT][NEUTRAL] And then the the surgery maybe 2025.
[AGENT][NEUTRAL] I guess those too.
[AGENT][NEUTRAL] You pay $50. Is that the last one?
[AGENT][NEUTRAL] OK, hello Ms. [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] Alrighty, so thank you so much for holding. I apologize for that wait, but I got all the information for you. OK, so,
[CUSTOMER][NEGATIVE] Not at all.
[AGENT][NEUTRAL] The first um line on here is for the first occurrence benefit, um, with the positive diagnosis. So that one was dated [PII], but it was denied because that first occurrence benefit is one per lifetime. So even if there's another positive diagnosis, if it's been paid out once, it won't pay out again for that lump sum.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK, so, OK, so because I'd already got paid for the first type of cancer, they don't do another one for a lifetime, OK.
[AGENT][NEUTRAL] Yes, ma'am. OK, so yes, you did that right. So then that was the first one. So then also on [PII], there was a surgery charge. Now that one is asking, well, actually I can do them together. It was a surgery and anesthesia charge. Those both are asking for the itemized surgery bill. So you would just um contact the hospital and ask them for the universal bill.
[CUSTOMER][NEUTRAL] Is that what I understood? OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For date of service, [PII].
[AGENT][NEGATIVE] And stress to them that you want their copy, not the patient copy, because the patients, your copy has itemized bill itemized codes too, but it just shows the treatment that you see and what you paid for it, the universal bill shows why.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then the surgery. So that's the difference between those two. So we're just needing that universal bill with the um procedure codes, so that's CPT codes like Charlie, Paul, Tango.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The diagnosis
[CUSTOMER][NEUTRAL] Charlie Paul Tango CPT codes.
[AGENT][NEUTRAL] Mhm. The diagnosis codes, um, that's also ICD like igloo, Charlie, David, and then the number 10.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All of the er
[CUSTOMER][NEUTRAL] And these are both come from the hospital?
[AGENT][NEUTRAL] Mhm. It'll all be, so the, the universal bill is like the big bill that your bill is generated from. We need that bill, the big bill.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, OK, and then on it it's gonna have that CPT codes and the ICD 10.
[AGENT][NEUTRAL] So it has everything.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Diagnosis codes in that? OK.
[AGENT][NEUTRAL] Yes, ma'am, and all the surgery charges, uh, and anesthesia charges, every, everything they did, it will be on that bill.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Does it say on there, isn't it, wasn't it Harris Southwest that I went to?
[AGENT][NEUTRAL] Um, hold on.
[CUSTOMER][POSITIVE] I can't even think right now. I think that's right.
[AGENT][NEUTRAL] It's OK.
[CUSTOMER][NEGATIVE] Isn't that horrible. I've had so much going on. Like, obviously, I've had 2 or 2 cancers in less than a year.
[AGENT][NEUTRAL] No, you've been through a lot. Right.
[AGENT][NEUTRAL] Right, no, that's just not at all. Um, let me pull the documents and see if I can see because it doesn't list the provider here, it just lists.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Like the benefit
[AGENT][NEUTRAL] Um, so I'll pull that and look and look and see if I can find the doctor for that.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, so that's surgery.
[CUSTOMER][NEUTRAL] I think it was Harris Southwest.
[AGENT][NEUTRAL] Hold on, is there a way?
[CUSTOMER][MIXED] It's kind of messed up but it's not messed up like I'm grateful for what they've been able to do but you can't help that you got two different types of cancer in a year like you know what I'm saying like for so for the like to be once in your lifetime like but again I'm like I'm thankful because I didn't even, you know what I mean.
[AGENT][NEUTRAL] OK, I'll go
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, but if it happens again, you know, you would want to be able to use, I guess because it's such a big
[AGENT][NEUTRAL] Hey, I don't know, but I understand what you're saying. I will look through the, um, because you remember how I said it's a lot and and we put them all into one, so I'll have to look through these to see what the provider is. You want me to keep going and then do that at the end or?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Don't worry. I, I think it's, I think it's here at Southwest. Don't worry about it.
[AGENT][POSITIVE] You sure? Because I don't mind.
[CUSTOMER][NEUTRAL] I'll look it up if not mhm I am. No, it's OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, um,
[AGENT][NEUTRAL] OK, so we did surgery, anesthesia, and then so there was one on here, [PII] for labs, that was denied because labs aren't covered by the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, there was an office visit from [PII]. The office visits are not covered on this policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] I think I just grabbed everything they sent me and just uploaded it because I'm not sure, you know what I mean.
[AGENT][NEUTRAL] As you should, because all the, the worst we can say is no, if a payment can happen, let's get it.
[CUSTOMER][NEUTRAL] Mm mhm.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Right. Right, right.
[AGENT][NEUTRAL] Um, the next one was [PII]. It said, uh, Myriad or Myra genetics.
[AGENT][NEGATIVE] Um, but it wasn't, it wasn't covered by the policy, so that was denied.
[CUSTOMER][NEUTRAL] Uh-huh, yeah.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] Then you had [PII] for.
[AGENT][NEUTRAL] Well, actually, I can do them together. [PII] and then [PII]. Those were denied, um they were MRIs, but the max had been met for medical imaging for for [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then, OK, so I did both of those and then [PII]. Now this
[AGENT][NEUTRAL] Looks like it was the, um, you have a mastectomy daily hospital um confinement benefit. So that one paid out $100 because it's $50 per day, so it paid for 2 days.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then,
[AGENT][NEUTRAL] The actual surgery mastectomy surgery, the policy pays $25 per surgery, so it paid $50.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then that was all the dates I saw for [PII] on that claim.
[CUSTOMER][NEUTRAL] OK, so I just need to contact.
[CUSTOMER][NEUTRAL] [PII] and I need to ask for a universal bill for [PII], their copy, not the patient copy, and I need to make sure it has the CPT codes and the ICD 10 codes on it and make sure it covers the surgery charges and the uh anesthesia charges, correct?
[AGENT][POSITIVE] Yep, you got it. Mhm. And as soon as we receive it, we'll continue processing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, sounds good. Thank you so much.
[AGENT][POSITIVE] You're very welcome, [PII]. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, ma'am, that's it. I appreciate it.
[AGENT][POSITIVE] You're welcome. Well, thank you for calling APL. I hope you have a good day.
[CUSTOMER][POSITIVE] Thank you. You too.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye.