AccountId: 011433970860
ContactId: 846cac4d-cf04-4f17-8797-c1bd240f2f86
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1173660 ms
Total Talk Time (AGENT): 486473 ms
Total Talk Time (CUSTOMER): 401059 ms
Interruptions: 3
Overall Sentiment: AGENT=0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/18/846cac4d-cf04-4f17-8797-c1bd240f2f86_20250318T21:22_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], my name is [PII]. I was just checking on a claim we submitted.
[AGENT][POSITIVE] All right, [PII], I'm happy to check on a claim for you today. Do you have a policy number?
[CUSTOMER][NEUTRAL] Uh, yeah, give me one second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Walking in the front door.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Oh it's darker so my sunglasses on.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Policy number is gonna be 254-8904.
[AGENT][NEUTRAL] All right, thank you. One moment.
[AGENT][NEUTRAL] And if I could just verify first name, last name, date of birth on the policy.
[CUSTOMER][NEUTRAL] Um, for the policy holder or from, uh, is [PII].
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh, birthday [PII].
[AGENT][NEUTRAL] Thank you and then what's the address that we would have on file for you guys?
[CUSTOMER][NEUTRAL] Uh, it should be [PII].
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Was the claim um under your name?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's a claim under in my in my wife's name.
[AGENT][NEUTRAL] And your wife, OK.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] All right, let me take a look.
[CUSTOMER][POSITIVE] Good
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] Go, go.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, it looks like there was a claim submitted about 5 days ago under her policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It looks like
[AGENT][NEUTRAL] We're gonna need it looks like more information on it. It was denied. So,
[AGENT][NEUTRAL] It's saying that based off of the effective date of coverage, it's necessary that we have past medical history to determine if this was pre-existing. Please com
[CUSTOMER][NEUTRAL] We've, we've had a policy though for she's had it been covered under a policy for the past 3 years.
[AGENT][NEUTRAL] I think they let me see if they sent something out here, one second.
[CUSTOMER][NEUTRAL] Because I remember we got that or she, she told me that that they had sent that but it was like oh like we had a policy for 3 years.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That that that would have covered it.
[AGENT][NEUTRAL] OK, so she got that and then sent it back.
[CUSTOMER][NEUTRAL] Yeah, I think we've submitted. I've been the one submitting everything that's why I'm checking on it, but uh.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm pretty sure we sent in what they asked for.
[AGENT][NEUTRAL] I see attached on call records blah blah blah, OK.
[AGENT][NEUTRAL] OK, so it looks like we did send something off to the provider also, um, Texas Oncology, we just got something back from them too.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I would give this maybe another day or so because like I said, I just see that that request was uploaded.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] What did you, what did y'all need from them? Does it say because we had had a, I think we got a position statement and everything and sent that in.
[AGENT][NEUTRAL] Yeah, they, I mean, under the, yeah, under the denial it just says checking for preexisting based off of the effective date that and then.
[CUSTOMER][POSITIVE] Pretty sure we got some.
[AGENT][NEUTRAL] Um, it looks like the only other thing says no surgical benefit. Policy provides limited benefits for treatment. The procedures submitted on a recent claim submission are not covered. Cancer treatments as listed within the policy. Therefore, no benefit was payable.
[CUSTOMER][NEUTRAL] But if, if I'm, if I, yeah, she hasn't had any surgery, well, she did, she had her port, she had her port placement for the cancer, but if I, if I, if I'm read the, the coverage correctly, a colonoscopy is covered, correct, uh diagnostically.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm. OK.
[AGENT][NEUTRAL] Let me see. I need to pull the policy and check.
[CUSTOMER][NEUTRAL] Because I think that's what I was reading it when my wife called and I guess she someone spoke, she spoke to someone.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh they, I was reading the coverage and I'm pretty sure it said as to the diagnose a colonoscopy is covered.
[CUSTOMER][NEUTRAL] Which is that would have been the only type of surgery, I guess.
[CUSTOMER][NEUTRAL] That she had done other than the port placement.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, for biopsy, I guess.
[AGENT][NEUTRAL] Yeah, I don't know. This 1 may have been a biopsy. Let me see.
[CUSTOMER][NEUTRAL] I can't, I can't remember what all we fit in. I know the.
[CUSTOMER][NEUTRAL] When they did, she did the colonoscopy, we had a biopsy done at, she did it while she was, you know, in there, I guess. And then the oncologist.
[CUSTOMER][NEUTRAL] Had him do a liver liver biopsy as well, but that was a needle biopsy.
[CUSTOMER][NEUTRAL] When they did the port placement.
[AGENT][NEUTRAL] OK, so yeah, that was the biopsy. So let me see what this says here.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] I wonder if there's, is this the only policy that you guys have with us? Do you know?
[CUSTOMER][NEUTRAL] Mhm. Well, like I've let me click back on here real quick.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we've had group cancer insurance for since [PII].
[CUSTOMER][NEUTRAL] But I don't know if it's the same. I'm assuming it's the same policy because it's the product name is the same.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, what was submitted and denied showing um not covered under the surgical benefits was, what was, what was submitted to us was the procedure code, the biopsy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it wasn't the actual testing where um she had a colonoscopy. So that's not the procedure that was sent to us because I went back in the policy and was double checking because it talks about like a surgery benefit in the policy, but the diagnostic testing benefit.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] is applicable to the colonoscopy. That's just not what this specific denial was for.
[CUSTOMER][NEUTRAL] OK, I think, I think so I think what I submitted to y'all was the um.
[CUSTOMER][NEUTRAL] The pathology report maybe?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So from what I can see, you don't need to submit anything else because the hospital and you have submitted the um documentation requested for the pre-existing portion.
[AGENT][NEGATIVE] Um, and the biopsy, I don't show there was any benefits for that on the policy, unfortunately.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah, so I need to submit something for the, like the colonoscopy from the GI doctor, I guess.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Right, so that would be separate, and then let's see, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Cause it's like the internal cancer, it's like the lump sum benefit and then it covers like the chemotherapy and stuff like that.
[AGENT][NEUTRAL] Yeah, so let's, OK.
[CUSTOMER][NEUTRAL] Oh, I see where they're talking about the preexisting because it's talking about like the waiting period or whatever, but that should be.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Voided since we had a we had a continual policy like each year, right?
[AGENT][NEUTRAL] Yeah, I feel, yeah, it should be. I let's see with the
[CUSTOMER][NEUTRAL] At least that makes sense.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So, on the um pathology report that you had submitted to us, you were using that to try and get the first occurrence payment. Is that what you were wanting for that?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, that we're that to get started, yeah, because at the time we hadn't we hadn't.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm trying to think.
[CUSTOMER][NEUTRAL] If she had already had her first chemotherapy treat, yeah, because I think we thought that that was all it covered. And then once I started reading the coverage, I realized that it covered like the diag diagnostic, like the uh colonoscopy, then it covered chemotherapy and then I think if I read it correctly, it covers like missed work or something maybe I can't remember.
[AGENT][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, they said something about profit or or something about loss of profit or something.
[AGENT][NEUTRAL] Yeah, I know, it it definitely does cover more than just the uh the one lump sum payment. So let me see.
[CUSTOMER][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Yeah, we're trying to just get started with that and then um like I don't like she's done, she's done her second round of chemotherapy like her second treatment. We just don't have any, I don't have the.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I need to get the paperwork from that to send in to get that benefit.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, and that, I'll be honest, that's, you know, um, some people will just do it like once a month, submit all the chemo, and then some people will do it every time. So it's really just personal preference, what you feel like is easier for you, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I was just trying to get started with the one claim and then uh once that came in start so I should have enough documentation of the other stuff and be able to talk to somebody and say hey I need this, this, this and this.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, let's see.
[CUSTOMER][NEUTRAL] To submit
[AGENT][NEGATIVE] Never
[AGENT][NEUTRAL] I don't even think that they may. Let me see what else is.
[AGENT][NEUTRAL] Requested I'm wondering if with that pathology I'm wondering if they're holding off on any approval on the claim until they had gotten that other paperwork um from the provider making sure it wasn't.
[AGENT][NEUTRAL] Like pre-existing, um.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see
[CUSTOMER][POSITIVE] Wow
[CUSTOMER][NEUTRAL] That's what was weird when I, when I read that on the denial. I'm like, well if it's it's preexisting oh well it was under the last policy number we had them.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You know, that I was like I was like, well, we've been covered for 3 years, I mean.
[AGENT][NEUTRAL] Yeah, no, it
[AGENT][NEUTRAL] Yeah, and it looks like there were just some changes like in the policy number, um, because I remember some of these, um, yeah, I remember some of these cancer ones. um, yeah, they had, they had changed and all of that, so, um.
[CUSTOMER][NEUTRAL] Uh, yeah.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEGATIVE] But anyhow, yeah, no, it, it definitely shouldn't, the preexisting, I don't think is applicable and it's unfortunate because
[AGENT][NEUTRAL] There are so many.
[AGENT][NEUTRAL] Situations where you just gotta make sure you double.
[AGENT][NEUTRAL] Check your T's and I's, you know.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Oh, abs, trust me, I'm, this is a whole new experience for us and.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] My um
[CUSTOMER][NEUTRAL] That's definitely something we've had to like really pay attention to.
[AGENT][NEUTRAL] Well
[AGENT][NEGATIVE] Right. And it's just unfortunate that
[AGENT][NEUTRAL] There are just people that would take advantage too so then companies have to, you know, double check stuff and assist you that mess.
[CUSTOMER][NEGATIVE] Yeah I know and and that's the thing it's like you gotta jump through so many hoops with people and it's frustrating and then it's like I'm only having to do this because there's because of people out there that would lie and cheat and about something like this.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, cause, right, [PII] decided, you know, um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. So it does say that the documentation needed for the first occurrence is just that pathology. So,
[CUSTOMER][NEUTRAL] But uh,
[CUSTOMER][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I mean, I don't
[CUSTOMER][NEGATIVE] Yeah, that's what threw me off with the with the, the denial deal. I mean, I guess I get the preexisting bit, but.
[AGENT][NEUTRAL] Right, right.
[AGENT][NEUTRAL] So I would do this. I would honestly, it's towards the end of the day today, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I would honestly give us a call back if you have time tomorrow and see if there's any um update on it because all of that information from the provider was uploaded just today.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] And then that way.
[AGENT][NEUTRAL] Like I said, all I'd ask for is that pathology report, so I feel like you should be fine, but
[CUSTOMER][NEUTRAL] Right, and then as far as like the diagnostic part, like I need to get something from the for the from the GI about the colonoscopy like to send in a secondary that and then the chemotherapy treatment stuff from the oncologist, OK.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] Right, yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, so like for the actual, um, yeah, colonoscopy. Uh-huh.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK and then um.
[CUSTOMER][NEUTRAL] Is there any, is there coverage for like having to miss work or anything like that? Um.
[AGENT][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] I could or or like what else what should I be looking for to collect to turn in that is covered?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] more
[CUSTOMER][NEUTRAL] Sorry
[CUSTOMER][NEUTRAL] She might still be out there.
[AGENT][NEUTRAL] I don't see anything on here in regards to missed work.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEGATIVE] OK, I, I, it was the way that the way that stuff is worded is so confusing and that's why I was like I didn't understand like the loss of profit or what I didn't understand what that meant.
[AGENT][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, no, it is, it's definitely confusing, [PII]. Yeah, I totally agree and I advise people on it, so.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Um, but yeah, no, if you guys, I mean, if, if at any point, you know, um, cause it is a lot, if, you know, you have questions or concerns, feel free to call us. We're, we're happy to help, OK?
[CUSTOMER][NEUTRAL] Hang up.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, sounds good so I will, uh, I guess call back tomorrow like you said.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then I'll gather that other information uh for uh to submit secondary.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All right, sounds good, [PII]. Is there anything else I can check on for you?
[CUSTOMER][POSITIVE] No ma'am, you've been very helpful, much more helpful than the other insurance company I talked to today.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] Oh, well, I'm so glad to hear that. And again, if you need us, just give us a call.
[CUSTOMER][POSITIVE] Alright thank you I will.
[AGENT][POSITIVE] All right, be blessed.
[CUSTOMER][NEUTRAL] All right bye bye.
[AGENT][NEUTRAL] Bye bye.