AccountId: 011433970860
ContactId: 8b63cd99-3d09-4c58-9a3a-8bcc284adcaa
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1439569 ms
Total Talk Time (AGENT): 450133 ms
Total Talk Time (CUSTOMER): 401537 ms
Interruptions: 3
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/15/8b63cd99-3d09-4c58-9a3a-8bcc284adcaa_20250415T20:15_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] on the care team. I've got a member that um wants to.
[CUSTOMER][NEUTRAL] I've been going through his claims with him, but he wants to know about the diagnosis if it can be pulled from a different claim for other claims we denied so.
[AGENT][NEUTRAL] Alright, what's his policy number?
[CUSTOMER][NEUTRAL] Policy number is 1220189.
[AGENT][NEUTRAL] OK, and the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh, patient is.
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I've got the claim numbers.
[AGENT][NEUTRAL] He's asking about the diagnosis code.
[CUSTOMER][NEUTRAL] So there's 3 claims for chemo drugs that he submitted.
[CUSTOMER][NEUTRAL] And it has the listing of the chemo drugs and the bill charges, but there's no diagnosis listed on the claims itself.
[CUSTOMER][NEUTRAL] So he's saying can we reference the claim that we paid out on for him?
[CUSTOMER][NEUTRAL] But I didn't think that we could, and
[CUSTOMER][NEUTRAL] Yes all documentation.
[AGENT][NEUTRAL] OK, give me one of the claims, give me one of the claims number. He's questioning.
[CUSTOMER][NEUTRAL] You know, that have
[CUSTOMER][NEUTRAL] 321-655-57.
[AGENT][NEUTRAL] And the date, the date of service.
[CUSTOMER][NEUTRAL] I guess it's uh well [PII] and then to [PII] [PII] and then [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] It's the chemo is what he's questioning the chemo charges.
[AGENT][NEUTRAL] to get
[AGENT][NEUTRAL] One second, try to get my little ducks in a row.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] It looks like with the chemo charges we're needing an explanation of benefits from his um.
[AGENT][NEUTRAL] The primary carrier, but you can send them over.
[CUSTOMER][NEUTRAL] OK, I didn't know. Do they require explanation of benefits? I thought that was only on Medin.
[AGENT][NEUTRAL] No, on some of the cancer policies they have to have the explanation of benefits because we paid the um the actual charges and so the explanation of benefits usually will have the actual charges.
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] OK, OK, alright, I'm gonna send him on over to you, OK?
[AGENT][POSITIVE] All right, thank you, [PII].
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, how are you, [PII]? Um, I need to review a claim with you. Um,
[CUSTOMER][NEUTRAL] For to see what what what's uh what's going on with that claim and.
[CUSTOMER][NEUTRAL] Why is it not getting through?
[AGENT][NEUTRAL] OK all right
[AGENT][NEUTRAL] And uh do you have a claim number?
[CUSTOMER][NEUTRAL] Uh, yes, it would be um 358-8.
[CUSTOMER][NEUTRAL] 062.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, it looks like that claim was for chemo, is that correct?
[CUSTOMER][POSITIVE] That's correct.
[AGENT][NEUTRAL] OK, it looks like we're needing the explanation of benefits from um your major medical.
[AGENT][NEUTRAL] So that we can finish the process.
[CUSTOMER][NEUTRAL] Yeah, so CVS, CVS Caremark was the uh.
[CUSTOMER][NEUTRAL] Provider for them, uh, because it's a specialty drug, right? Uh, it was immunotherapy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And do you, do you have a primary insurance carrier?
[CUSTOMER][NEUTRAL] Um, so in previous
[CUSTOMER][NEUTRAL] Well, it is
[CUSTOMER][NEUTRAL] The CVS Caremark uh TRS active scare, uh, segment of it. So, you know, Texas teachers, we get, uh,
[CUSTOMER][NEUTRAL] Primary care, uh, with, uh, through TRS Active Care, which pairs up with CVS Caremark.
[AGENT][NEUTRAL] OK. And so your major medical, you said is with who is it, like Blue Cross, United Healthcare, or?
[AGENT][NEUTRAL] Cigna, who is your primary carrier?
[CUSTOMER][NEUTRAL] Well, it is, it is called uh TRS ActiveCare.
[AGENT][NEUTRAL] OK and so um.
[CUSTOMER][NEUTRAL] It's a teacher and teacher retirement system of Texas.
[AGENT][NEUTRAL] OK, so we would need the explanation of benefits from them.
[AGENT][NEUTRAL] That shows how they process the charges from CVS specialty.
[CUSTOMER][NEUTRAL] They, OK, so the, the provider is itself uh CVS Caremark. It's not uh just a provider of the drug, but they actually take care of uh health benefits for that aspect of.
[AGENT][NEUTRAL] OK, I understand. I, I understand that. But the, but the TRS did the, how did they process the claim from CVS for the drugs? Did they, did uh
[CUSTOMER][NEUTRAL] The TRS
[AGENT][NEUTRAL] Did they process and make a payment?
[CUSTOMER][NEUTRAL] They, they, they, they don't.
[CUSTOMER][NEUTRAL] They don't get involved, uh, if, if you, OK, so what part of the problem is that, um, some of the claims previous claims that I submitted, they went to the wrong policy number. So if you check uh claim number 3581.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 751 and 3581747.
[CUSTOMER][NEUTRAL] You will find the not only the billing but also on the explanation.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, give me one second.
[CUSTOMER][NEUTRAL] Of course.
[AGENT][NEUTRAL] OK, I checked um [PII] and that's still just the um the statement from CVS.
[AGENT][NEUTRAL] Uh, so that's not an explanation of benefits on that one.
[AGENT][NEUTRAL] And let me check the other one.
[CUSTOMER][NEUTRAL] It is um
[AGENT][NEUTRAL] 25.
[AGENT][NEUTRAL] OK, I'm checking the other one.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] And it looks like it's the um same information under the other one is still just a statement.
[AGENT][NEUTRAL] Of the patient's calls from CVS. The information is from CVS.
[AGENT][NEUTRAL] And so you did not get uh.
[CUSTOMER][NEUTRAL] It is, it's, it's, it's not just the pharmacy, CVS, it's CVS special. It's separate, uh, since this was an immunotherapy drug that was supplied.
[AGENT][NEUTRAL] OK, so what we are needing.
[AGENT][NEUTRAL] Is the information from.
[AGENT][NEUTRAL] You said TPRS like or TRS?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so we need the information from them.
[AGENT][NEUTRAL] That shows how they process these charges from CVS.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] How they process the
[CUSTOMER][NEUTRAL] The billing
[AGENT][NEUTRAL] Yes, how they process the, the drugs that you got from CVS. So when uh when you got these drugs, the CVS file a claim with TRS?
[CUSTOMER][NEGATIVE] Uh, they do not.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It gets applied directly, so you have a, you have a provider uh from the hospital name the Anderson, and they send this uh prescription to the provider which is Caremark Specialty Pharmacy, uh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That uh goes.
[CUSTOMER][NEUTRAL] Directly and that they process with
[CUSTOMER][NEUTRAL] Whatever benefits they have uh under their program.
[CUSTOMER][NEUTRAL] And then they give you uh uh for example, the, the statement of patient costs.
[AGENT][NEUTRAL] OK. And so you don't use, uh, I guess TRS does not pay any benefits for any drugs or anything like that? Is that what you're saying?
[CUSTOMER][NEUTRAL] That's correct. Yeah, they they, they, they don't have um
[CUSTOMER][NEUTRAL] A uh Blue Cross Blue Shield or whatever.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I mean, some, sometimes they do, they, they change that year by year.
[AGENT][NEUTRAL] OK. Let me see what else because we uh we have to see the actual charges and so usually if there's somebody like TRS or Blue Cross and Blue Shield, that explanation of benefits would have the actual charges listed there.
[AGENT][NEUTRAL] Uh, let me see if there's something else that we can.
[CUSTOMER][NEUTRAL] The actual charges for um
[CUSTOMER][NEUTRAL] I mean that in the statement of patient costs they have the total charges.
[AGENT][NEUTRAL] No, actual charges. I mean, they may have if they gave you a discount, then they may just have that sometimes they just may have the discounted cost.
[AGENT][NEUTRAL] Uh, but usually, if it goes through a major medical, it's gonna have the actual cost on it.
[AGENT][NEUTRAL] So give me just one second so that I can see if there's something else that we can use. Can you give me 1 2nd please?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Alright thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hey [PII], how's it going?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Good. Uh, I have a question. I'm gonna share my screen and let you look at it. I have a gentleman on the phone, and so we uh processed his claim for I guess the chemo drugs that he received, and we were asking him for the explanation of benefits, and he says that there is no explanation of benefits that he can get.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Uh, for this, he has like TRS I guess it's like some type of Texas, uh, retirement something.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So he said
[AGENT][NEUTRAL] Yeah, that's what it is, a teacher's retirement something, um.
[AGENT][NEUTRAL] So he said there is no explanation of benefits, so.
[AGENT][NEUTRAL] What else can he send in?
[AGENT][NEUTRAL] That would show like the, I know that explanation of benefit is needed to see the actual charges.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Have you
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Uh, yes, yeah.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] He did. He had a
[AGENT][NEUTRAL] The GC 14.
[AGENT][NEUTRAL] No, he didn't. He had met me before.
[AGENT][NEGATIVE] Yeah, we've asked several times and each time he's sitting in the same thing looks like.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Uh, [PII] did this one that I'm looking at, well, let's see, she, she did the last one.
[AGENT][NEUTRAL] That was done on April.
[AGENT][NEUTRAL] That person to reach out and um once we have that for for an update.
[AGENT][NEUTRAL] OK, OK.
[AGENT][POSITIVE] Alrighty.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] OK, OK.
[AGENT][POSITIVE] OK alright thank you so much, [PII].
[AGENT][NEUTRAL] All right bye bye.
[AGENT][NEUTRAL] OK, Mr. [PII].
[AGENT][NEUTRAL] I hope I said that correctly. OK.
[CUSTOMER][NEUTRAL] Mhm. [PII]
[AGENT][NEUTRAL] OK, um
[CUSTOMER][NEUTRAL] [PII], yeah, that's fine.
[AGENT][NEUTRAL] OK, thank you. OK, so what we're gonna do is we're gonna try to get this one reviewed and we're gonna see if we can call CVS um to see if we can verify the actual charges on this information and do you have a callback number that someone can probably call you back once we uh research this a little bit more?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh yes, it's [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and I'm gonna read that back just to make sure I have it correct. I have [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 257-775-3, is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Correct. Yes.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All righty.
[CUSTOMER][NEUTRAL] And also just to verify that you have the information, uh.
[CUSTOMER][NEUTRAL] Can you
[CUSTOMER][NEUTRAL] Just uh, quick, uh, really quick check if you have the information from Caremark so you can call uh CVS and.
[CUSTOMER][NEUTRAL] Verify the information so you have
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Patient name
[AGENT][NEUTRAL] Yes, I have your name, yes sir.
[CUSTOMER][NEUTRAL] Yeah, prescriber and all the costs.
[AGENT][NEUTRAL] Yeah, we're gonna, we're gonna just call the uh.
[AGENT][NEUTRAL] We're gonna use the information that you sent in to us that says uh CVS Caremark.
[AGENT][NEUTRAL] And it does list the drug, list the um the type of drugs that you were and the dates of service.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So it, yeah, send it to him.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And it does
[CUSTOMER][NEUTRAL] Should I wait on the phone or who who is who is going to review?
[AGENT][NEUTRAL] Uh, the examiner that processed your claim, so I don't know how long it's gonna take because we're gonna have to try to call CVS.
[CUSTOMER][NEUTRAL] The claim.
[AGENT][NEUTRAL] Um, to verify with them and so once we finished the verification process, then someone will give you a call back. We'll have, I'll have her to give you a call back to let you know what's going on.
[CUSTOMER][NEUTRAL] OK, so, um.
[CUSTOMER][NEUTRAL] Yeah, sure, uh, you guys can call, uh, CVS Caremarkt. Uh, you have all the information and if not.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'll give you guys a call back. Uh, what would, what would be a good extension number?
[AGENT][NEUTRAL] Uh, you can just call the number that you called, um, but someone should give you a call back. It probably, I don't know if it'll be this evening or not, but I would say maybe about if you haven't heard from us by the end of tomorrow, you can give us a call back to see if we have been able to make contact with them.
[CUSTOMER][NEUTRAL] OK, uh, yeah, I'm going to independently call, uh, CBS car market just to, uh, give them a heads up.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Like you guys might need um some further information I guess um.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] Alright, I, I actually I got transferred many times, uh, to get, uh, I'm guessing you reviewed claims.
[AGENT][POSITIVE] Yes, yes, yes, that's correct.
[CUSTOMER][NEUTRAL] [PII], right?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so you review claims and now a next seminar is going to look at the claim?
[AGENT][NEUTRAL] Yeah, so I am in like the uh the claim support so if you have an issue with your claim, uh, you can contact me um usually the call will be transferred to me and I'll see if I can help you, uh, and if I can or if claim needs to be reprocessed, then we just send it back to the end to that examiner to review it for processing, but she's gonna do the leg work to see if she can get the information that's needed.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, um, do, do you know who the examiner would be for, for this, uh, claim?
[AGENT][NEUTRAL] I, I do, but, uh, I'll just wait, we'll just let her give you a call back because like I said, I don't know if she'll be able to contact anyone or make contact with anyone this evening because it is kind of late. People start leaving work maybe [PII]ish.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So I would say give us until tomorrow evening.
[AGENT][POSITIVE] And hopefully we'll be able to, someone will be will have contacted you before that time.
[CUSTOMER][NEUTRAL] OK, uh, well, as long as, uh, you don't need to give me the extension number, just, uh, the the name of the examiner so I can just go straight and ask someone to transfer me to her.
[AGENT][NEUTRAL] Um, I mean, we really don't give out the names of the examiners.
[CUSTOMER][NEUTRAL] OK, so, but the examiner is going to contact me tomorrow.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] What?
[AGENT][NEUTRAL] Yes sir, she'll be someone will be contacting you on tomorrow.
[CUSTOMER][POSITIVE] Alright, perfect. I'll, I'll give a call to CVS and then uh.
[CUSTOMER][NEUTRAL] We'll talk tomorrow then.
[AGENT][NEUTRAL] OK, alrighty, was there anything else that you needed um assistance with on today?
[CUSTOMER][POSITIVE] Uh, not for now, thank you.
[AGENT][POSITIVE] OK, alright, well thanks for calling ATL. You have a great rest of your day.
[CUSTOMER][POSITIVE] Thank you, [PII]. You as well.
[AGENT][NEUTRAL] OK, bye-bye.