AccountId: 011433970860
ContactId: 92a3e8e4-da78-4d5e-b3f3-e04992b8ebce
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1180770 ms
Total Talk Time (AGENT): 375360 ms
Total Talk Time (CUSTOMER): 383007 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/92a3e8e4-da78-4d5e-b3f3-e04992b8ebce_20250225T16:46_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling Apolis [PII]. How can I help you?
[CUSTOMER][NEUTRAL] [PII], my name is [PII]. I'm calling on behalf of my wife.
[CUSTOMER][NEUTRAL] Her name is [PII]. Her policy number is 0053.
[CUSTOMER][NEUTRAL] 2280
[CUSTOMER][NEUTRAL] We send in some uh
[CUSTOMER][NEUTRAL] Some claims and uh I got a letter back said you've received the claim and
[CUSTOMER][NEUTRAL] I was wondering if you have any questions for me in in going over what we sent you.
[AGENT][NEUTRAL] OK, Mr. [PII], I can help you with that. Can I get your callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, it is [PII].
[CUSTOMER][NEUTRAL] [PII] you're [PII]?
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so you said you had questions about the claim that you had sent in for Ms. [PII]?
[CUSTOMER][NEUTRAL] Well, I was wondering if you had any uh any questions for me and what we sent in.
[AGENT][NEUTRAL] OK. Um, no, actually, um, actually, um, her claims were processed on yesterday, so, um.
[AGENT][NEUTRAL] So yes, they were passed on yesterday, so there are gonna be 3 separate checks that are being mailed out.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, do you have any idea of what those amounts are?
[AGENT][NEUTRAL] Yes, sir, so give me one second.
[AGENT][NEUTRAL] And also I'm not sure if you're aware, um, y'all are able to check on claim status on our website which is at [PII] um but let me pull up what those amounts are.
[AGENT][NEUTRAL] Excuse me.
[CUSTOMER][NEUTRAL] Is it still cool in [PII]?
[AGENT][NEUTRAL] Well, I actually, I'm, I'm a remote employee, um, but I believe that it is, but it's just not as bad as it's been.
[AGENT][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] It was cold here in [PII], [PII].
[AGENT][NEUTRAL] Yeah, and actually I live in [PII], so, um, I'm actually in [PII].
[AGENT][NEUTRAL] Uh let me see.
[CUSTOMER][POSITIVE] Well they got pretty cool down there for y'all didn't it?
[AGENT][NEUTRAL] Yes, sir, I did.
[AGENT][NEUTRAL] I'm sorry, my system is just running slow, so I'm waiting for it to come up, so.
[CUSTOMER][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] Yeah, we got down to 4 below here, windshields are 25 below.
[CUSTOMER][NEGATIVE] For a couple of days and it was brutal.
[AGENT][NEUTRAL] Oh wow. OK, so on one, because there's 3 different claim numbers, so there's gonna be 3 different checks. So on one of them, the amount is gonna be $3,023.47.
[AGENT][NEUTRAL] And let me, let me pull up the next one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So the second one is gonna be $1,308.45.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the last one, let me see.
[AGENT][NEUTRAL] Its $112.66.
[CUSTOMER][NEUTRAL] OK, I, uh.
[CUSTOMER][NEUTRAL] I'll have some questions about that whenever we receive, receive that because uh.
[CUSTOMER][NEGATIVE] We should have, we should have maxed that policy out with uh.
[CUSTOMER][NEUTRAL] Everything that we sent.
[CUSTOMER][NEUTRAL] Uh, she had the 10,000 extra rider on cancer.
[CUSTOMER][NEUTRAL] $2,020,000 maximum.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Uh, I.
[AGENT][NEUTRAL] Are you referring to uh chemo or?
[CUSTOMER][NEUTRAL] Chemo, yes.
[AGENT][NEUTRAL] OK, let me see what was paid on chemo and I can look at that one real quick.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] And so the way the um the chemo works, we go based off of the EOB um so the EOB we go based off the actual charges. So, um, so if you get it and it's not showing it's maxed out, that's the reason why, even though she has that on the policy, we can only pay what's um on the ELB as far as what what um what the responsibility was.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, was there some surgery benefits on one of those and then some transportation, uh.
[CUSTOMER][NEUTRAL] I said it, uh
[CUSTOMER][NEUTRAL] They paid me for 2 transportations back in the.
[CUSTOMER][NEUTRAL] Uh, the beginning of [PII] or the end of [PII].
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] The uh
[CUSTOMER][NEUTRAL] The additional slips payment receipts that I sent in, she had a total of 20.
[CUSTOMER][NEUTRAL] I believe it's 26 chemos, so we took 26 trips.
[CUSTOMER][NEUTRAL] Uh, I don't know whether any of this is for transportation.
[CUSTOMER][NEUTRAL] But uh
[CUSTOMER][NEUTRAL] We took 226/26 trips, excuse me, uh, to [PII].
[CUSTOMER][NEUTRAL] And that was
[CUSTOMER][NEUTRAL] I, I think it was anything over 50 miles. Well, that one way it's like 63 miles from our house to the point of where we got treatment and I was wondering if they paid anything on my transportation.
[AGENT][NEUTRAL] OK, so let me pull up that particular one.
[AGENT][NEUTRAL] I mean
[CUSTOMER][NEUTRAL] And there was some uh.
[CUSTOMER][NEUTRAL] Surgery and anesthesia benefits probably.
[CUSTOMER][NEUTRAL] Between the two different claims.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEGATIVE] I just, I don't see that the amounts that you give me.
[CUSTOMER][NEUTRAL] Should anywhere come near what we turned in as far as surgery and anesthesia and the chemos that she received.
[AGENT][NEUTRAL] So I can tell you as far as the surgery goes, um, was that for data service of July, I'm sorry, [PII]?
[CUSTOMER][NEUTRAL] No, it was for uh.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] [PII] when she had her actual surgery.
[AGENT][NEUTRAL] Of [PII].
[CUSTOMER][NEUTRAL] Of [PII].
[AGENT][NEUTRAL] OK, give me 1 2nd.
[AGENT][NEUTRAL] Where you
[AGENT][POSITIVE] Really cool.
[CUSTOMER][NEUTRAL] She, she actually had 4 surgeries in one. She had a.
[CUSTOMER][NEUTRAL] Complete hysterectomy.
[CUSTOMER][NEUTRAL] A colon resection.
[CUSTOMER][NEUTRAL] An appendectomy.
[CUSTOMER][NEUTRAL] And an almanectomy all at the same time.
[AGENT][NEUTRAL] Yeah, hold on.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so, um,
[AGENT][NEUTRAL] The surgeries were paid, um.
[AGENT][NEUTRAL] Hold on 1 2nd.
[AGENT][NEUTRAL] So yes, we paid on the surgeries.
[CUSTOMER][NEUTRAL] You did?
[AGENT][NEUTRAL] Uh, let me see. Yes, sir. 1918.
[AGENT][NEUTRAL] So as far as the, let me go on here.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So yeah, so the surgery for [PII].
[AGENT][NEUTRAL] I'm looking on here.
[AGENT][NEUTRAL] So that is included in one of the, the amounts. So, so for instance, and I can give you by procedure code, so the
[AGENT][NEUTRAL] One of them was the procedure code 58954 and that's for the total abdominal hysterectomy and amendectomy. So the amount
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] was for 2,07026 cents.
[AGENT][NEUTRAL] And then we pay the anesthesia for that same procedure of $243.84. So those surgeries um are included in the amounts that I gave you. Um, but like I said, if you, um, I'm not sure if you have access to the online portal, you can print, I mean, look at, or uh if you want to wait, like I said, it sends out an EOB and it shows the lines that we pay.
[CUSTOMER][NEUTRAL] OK, so, uh.
[CUSTOMER][NEUTRAL] These were paid on one of the checks that we're gonna receive.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] OK, so it looks to me like there was hardly anything paid on the chemos.
[AGENT][NEUTRAL] And then, that's why I was looking at, um, let me go back to the chemo portion, uh, cause I had went and jumped to the surgery. Um.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hold on 1 2nd.
[AGENT][NEUTRAL] So as far as the chemo goes, uh, let me see.
[AGENT][NEUTRAL] So on the policy, the chemo is only showing 10,000 per um let me go back to it I have it up. It's 10,000.
[AGENT][NEUTRAL] Hold on one second, I'm sorry.
[CUSTOMER][NEUTRAL] We have the extra rider on that for the additional 10,000.
[CUSTOMER][NEUTRAL] Do you know the person that that uh.
[CUSTOMER][NEUTRAL] That process these claims.
[AGENT][NEUTRAL] I actually processed it, but it went over to um to audit, um, and it was released by the audit team team.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, I, uh
[CUSTOMER][POSITIVE] We've got the additional $10,000 rider on the cancer on the chemo.
[CUSTOMER][NEUTRAL] So we should have a total of $20,000.
[CUSTOMER][NEUTRAL] And I think they've already paid.
[CUSTOMER][NEUTRAL] They've already paid 9 I believe.
[CUSTOMER][NEUTRAL] 9 or 10, I can't remember what the amount of that check was, but uh.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] I'm seeing in what you're showing me, if this, if this is just all included of the surgery, there's hardly not any chemos involved in this claim.
[CUSTOMER][NEUTRAL] From what we sent you, and then there's no transportation.
[CUSTOMER][NEUTRAL] That that I see.
[AGENT][NEUTRAL] OK, as far as the chemo goes, I mean, I can send this back to, I mean, our audit team and have them to relook at it. Um, as far as the transportation, um, according to the, the bills that we have, we go based off of the address that's there for whether the, um, the treatments are being done. And when we calculate it, um, it's showing less than 50 miles one way, um, the way we look it up.
[CUSTOMER][NEGATIVE] That's, that's not correct. That's not correct, ma'am. I've drove it. I've drove it over 100 times in the last 3 years, and I drove it for 11.
[AGENT][NEUTRAL] Yeah, I understand. So, so if you, when you get back to EOB and it shows something different, I mean, you can resubmit as far as the transportation goes, and you can put the address like write down the address and send it back to us.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I, I wrote down, I wrote down the addresses and sent them to you. And uh there's two different ways you can get over there and both of them are over 60 something miles.
[AGENT][NEUTRAL] Yeah, I understand like I said, so what, so what we do is we pull up our um we pull up a map and then we do um an address look up from your home and then to where it is. And like I said, when that was done, it was showing, let me pull up those um let me pull up those maps.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] So the one for um when the surgery was done on [PII], we pay the transportation for that particular one.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, which was $48.80 because it's 40 cents per mile.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And let me see what the other one is.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] And see, that's where the surgery was done, where she was getting her chemo is another.
[CUSTOMER][NEUTRAL] 3 or 4 miles, 5 miles into town.
[CUSTOMER][NEUTRAL] Uh, I, ma'am, I drove it. I've drove it numerous times, and you can't do it for less than 62 or 63 miles.
[AGENT][NEUTRAL] Yes, sir, I mean, I totally understand, but like I said, I mean I can send this back over to um our review team and have them to review it, but like I said, they, um, like I said, we paid for um the [PII] as far as transportation goes, um, we paid that benefit, um, but as far as the.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] The other ones, um, they were not coming back, coming out, but like so I can run it back over to them to see if they can um relook at it, but I mean, we've paid out um everything. So like I said, if you get something, when you get the EOBs back and you disagree with something, um, you're more than welcome to.
[AGENT][NEUTRAL] Um, give us a call [PII]ack and we can um take a look at it again to see what you're disagreeing with and what you think that should be paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, uh,
[CUSTOMER][NEUTRAL] I uh
[CUSTOMER][NEUTRAL] I don't know how y'all handle all this, but uh.
[CUSTOMER][NEGATIVE] This is, this is not.
[CUSTOMER][NEUTRAL] Uh, well, we'll just look at it whenever we get it, and we'll see what we come up with, but, uh, as far as transportation, I've got nearly 30.
[CUSTOMER][NEUTRAL] In [PII] alone, trips to [PII].
[CUSTOMER][NEUTRAL] Some of those which you shouldn't have to pay because they were office visits.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] From my house, I am north of [PII], out of this, I'm out of the city limits. I'm north of [PII].
[CUSTOMER][NEUTRAL] And then from my house to the city limits [PII] is 52 miles, and then from there to his office is another 12.
[CUSTOMER][NEUTRAL] It's on the far side of [PII].
[CUSTOMER][POSITIVE] So we'll we'll look at it when we get it in and I'm sure I'll be calling you back.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Uh, no problem, Mr. [PII]. Was there anything else that I can help you with today?
[CUSTOMER][NEUTRAL] No, ma'am. I just, uh.
[CUSTOMER][NEUTRAL] Yeah, with all that we sent you, I'm, I don't know uh.
[CUSTOMER][NEGATIVE] I'm not real pleased with the way that the doctor
[CUSTOMER][NEUTRAL] Does his billing.
[CUSTOMER][NEUTRAL] You know, we've uh.
[CUSTOMER][NEUTRAL] We've, we've been through a lot of chemos and
[CUSTOMER][NEUTRAL] It's uh
[CUSTOMER][NEUTRAL] It's just not all adding up.
[AGENT][NEUTRAL] Yes, sir, I understand.
[CUSTOMER][POSITIVE] I thank you, I thank you for your time and we'll be looking to hear from you.
[AGENT][POSITIVE] Alright, no problem, Mr. [PII]. Well, thanks for calling A2. You have a wonderful day.
[CUSTOMER][POSITIVE] Thank you. And your name is [PII]?
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][POSITIVE] All right, thank you.
[AGENT][POSITIVE] No problem, thanks for calling April. You have a wonderful day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Yeah