AccountId: 011433970860
ContactId: 95c76914-c5b7-46a9-94fc-3e496a972ba3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 774969 ms
Total Talk Time (AGENT): 298657 ms
Total Talk Time (CUSTOMER): 290605 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/24/95c76914-c5b7-46a9-94fc-3e496a972ba3_20250224T15:58_UTC.wav
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[AGENT][NEUTRAL] Calling ACL, this is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Hey [PII], it's [PII]. How are you doing?
[AGENT][POSITIVE] Good. How are you?
[CUSTOMER][POSITIVE] I'm OK for a Monday, working on my 2nd cup, hopefully it kicks in.
[AGENT][NEUTRAL] I understand.
[CUSTOMER][NEUTRAL] Well, um, I have [PII], he's calling from broker's office, Crescent City Benefits and he has a question about a claim status for a patient. Um, policy number 2271246.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And it's for the claim number 3566048.
[CUSTOMER][NEUTRAL] And he's questioning as far as the chemo where it states that we're needing itemized billing, um, showing the procedure codes and the charge amount, but he is stating per the information that was submitted it has the procedure code as well as the amount.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Can you give me that policy number because I'm a.
[CUSTOMER][NEUTRAL] Oh, I'm sorry. It's um 227-1246.
[AGENT][NEUTRAL] OK, part 2.
[CUSTOMER][NEUTRAL] Uh, part two, I'm sorry, yes.
[AGENT][NEUTRAL] And what was the policy, I mean, the claim number again?
[CUSTOMER][NEUTRAL] 356-604-8.
[AGENT][NEUTRAL] And for the chemo, OK.
[CUSTOMER][NEUTRAL] Yeah, I explained um that for that uh for the chemo, they're needing billing with the procedure codes and charge amount, but he is stating what they submitted does show chemo and does have a procedure code and the amount for the chemo.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, I have it um pulled up.
[CUSTOMER][POSITIVE] Awesome. Well, thank you, madam.
[AGENT][POSITIVE] Thanks.
[CUSTOMER][POSITIVE] All right, have a great one.
[AGENT][NEUTRAL] You too. Bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] This is [PII] in the claims department. Uh, you're calling about, good, good. You're calling about the chemo where we're asking for the procedure code.
[CUSTOMER][POSITIVE] Hey [PII], how are you doing?
[CUSTOMER][NEUTRAL] Yeah, yes, I was trying to find out, uh, the bills we had sent looks like it had some charges on [PII]. It does have some procedure code and it says chemo and under that it has another procedure code and says looprolide, you know, 33,000, and it has the charge. What, uh, what different were you looking for on there?
[AGENT][NEUTRAL] OK, let me take a look at um
[AGENT][NEUTRAL] What was the, what's the procedure code that you see on there? What, what, what
[AGENT][NEUTRAL] You said it's a procedure code, so what code are you seeing that
[CUSTOMER][NEUTRAL] It does
[CUSTOMER][NEUTRAL] Let's see, let's see, it's on page 4 of the of that last attachment that was sent in on [PII] um.
[CUSTOMER][NEUTRAL] On the [PII], I believe, uh, it shows charges, then it shows the codes next to the it shows date [PII]. Then it shows code 96402, then it says chemotherapy, hormone anti something and then it shows a $217 charge then it has another date and code.
[CUSTOMER][NEUTRAL] Then it says loop for 33,000.
[AGENT][NEUTRAL] Do you see a J code on there?
[AGENT][NEUTRAL] Do you see a J code?
[CUSTOMER][NEUTRAL] There's a code. There's a code underneath the chemo on the next charge J9217.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But I don't know what looprolite is, is that
[AGENT][NEUTRAL] at page 5. OK, so I, the last thing we have is we submitted on the [PII].
[CUSTOMER][NEUTRAL] Let's see it this is.
[AGENT][NEUTRAL] It was 100, 400 and some pages. Is that the same?
[CUSTOMER][NEGATIVE] OK, this is one, no ma'am, this is one that's on, it says they received 2525. It's an attachment that has 5 bills on it. It's only 5 pages.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Oh, OK. Let me look for that. Let me look for what you're looking at because I'm looking at one that had 400 and something pages.
[CUSTOMER][NEUTRAL] It shows
[CUSTOMER][NEGATIVE] I know they gave us that ridiculous file and I couldn't break it up better than that.
[CUSTOMER][NEUTRAL] But it does have all the surgery reports and everything on there.
[AGENT][NEUTRAL] Ok, so that's it.
[AGENT][NEUTRAL] L E U P R O L I D, that is a hormone.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] And we paid for the home loan for 1227.
[AGENT][NEUTRAL] So under the 5 pages you sent, pages um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We for
[AGENT][NEGATIVE] 96402, that is not a drug. That is like an admin. They don't pay for admin, that is not um.
[AGENT][NEUTRAL] That is not the drug. The drugs start with a J code, um, and that is the reason why we asked for the billing, the itemized billing. And sometimes they don't, um, that 96412 goes along with that hormone drug that they um injected.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is um J9217. That is a hormone that is not chemotherapy.
[CUSTOMER][NEUTRAL] OK, OK, I know he's about to go in for a full round of chemo, um.
[AGENT][NEUTRAL] So she got paid.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So on that $33,000 charge, that's where he got that $50 benefit. That's the only thing we paid for the hormone therapy.
[AGENT][NEUTRAL] Yeah, the hormone benefit for the policy is $50 per um hormone.
[CUSTOMER][NEUTRAL] OK, um, I know he's fixing to go for a full round of, uh, chemo if I understand it's gonna be next month, so I will get that from him as soon as they do that. When I get that, I need to make sure that that bill shows the J codes, is that right?
[AGENT][NEUTRAL] That is correct. When you see the J code, that, that is um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That is the code that we're looking for.
[CUSTOMER][NEUTRAL] OK, got it. And I know he had a surgery. I know the surgery reports are in the inside that the big file unfortunately, um, so that surgery report should have been in there. I know they said they had a question about a surgery.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] That was [PII]. Let's see what we're looking for.
[AGENT][NEUTRAL] [PII] 106.
[AGENT][NEUTRAL] You said in the um the other file, you said you submitted the um the surgery charges?
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] No, somebody was saying, um, when I just talked to somebody, they said they're missing a certain report.
[AGENT][NEUTRAL] Yeah, yeah. So it looks like it shows where they did have surgery that day or something happened on [PII]. So if we see where they did have something and um
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Then we'll pull that day out and ask for it. So it looks like we're asking for the charges and the pathology report. So it could have been a biopsy that was done that day. Um, and if so, we would need the charges for that biopsy and the path report because we will only pay for a positive diagnosis. So they did a path to see if, you know,
[AGENT][NEUTRAL] What was going on, if they had like a lymph node or something done, then we would need to pass for that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I did send in a a pathology report to get the claim started, so I guess that the claim is actually already open now since they already started paying some benefits, is that right?
[AGENT][NEUTRAL] Yeah, so if you submitted the path report to start the claim, then that means that the past report is from the um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The first initial diagnosis of cancer, but then as they perform surgeries and do other biopsies, like for every surgery, we don't need a pathology report only if they do a biopsy of it is where we would need the path to go along with it. And that usually um if you look at the claim form that's online, that's like a little sheet that tell you like what is needed for what um benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, um, if you go to like the cancer claim form that we have online.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It'll tell you um to submit the pathology report when you're submitting for um biopsies.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Got it. So, so, so the money that we've already um paid him just recently, is that, um, was that direct deposited?
[CUSTOMER][NEUTRAL] Can you see that on your side?
[AGENT][NEUTRAL] OK, whether it's direct or check. OK, hold on, let me see.
[AGENT][NEUTRAL] OK, so that was a direct deposited. This was processed on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Got it. OK, well, at least I know that the claim's open and once he starts going in for these big treatments that I can just send it over and it's already an open claim. So, um, that, that was my main priority to make sure it got opened and his direct deposit was set up and as it gets this big stuff done I will send it in with um.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I'll try to get UB04s because I know those work better.
[AGENT][NEUTRAL] They sure do. They sure do.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] I will definitely work on that for you and um.
[CUSTOMER][NEUTRAL] I have one more person that it looks like it's kind of sitting there. Would it be OK if I gave you their information?
[AGENT][NEUTRAL] OK, one moment, let me make notes on this policy, please.
[CUSTOMER][POSITIVE] Take your time.
[AGENT][NEUTRAL] All right, what is that policy number, please?
[CUSTOMER][NEUTRAL] OK policy number is.
[CUSTOMER][NEUTRAL] 251-087-3
[AGENT][NEUTRAL] 0873.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] And could you please verify the member's name and their date of birth?
[CUSTOMER][NEUTRAL] Yes, name and date of birth.
[CUSTOMER][POSITIVE] On my computer, it was always super fast. Something happened in the last week. I don't know how it got zapped, but it's uh it's acting crazy.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Um, it is [PII].
[CUSTOMER][NEUTRAL] And it's loading the date it's loading the date of birth right now I'm sorry.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, it looks like the date of birth on her should be [PII].
[AGENT][NEUTRAL] Alright, thank you so much for verifying the information. So it looks like we received those um documents um via the online center on [PII] um that one has not yet been reviewed um or has a claim number. Um we have um 7 to 15 business days for that, so, um.
[CUSTOMER][NEUTRAL] OK, I will circle back.
[AGENT][POSITIVE] But yeah, we did receive that on [PII]. That is correct.
[CUSTOMER][POSITIVE] OK, I appreciate your time thank you very much.
[AGENT][NEUTRAL] All right, [PII], is there anything else I can help you with today?
[CUSTOMER][POSITIVE] Thank you have a great day.
[AGENT][POSITIVE] Thank you for calling APL. Have a good day. Bye bye.
[CUSTOMER][POSITIVE] Thank you bye bye.