AccountId: 011433970860
ContactId: a01aa460-3a64-4661-85c7-190527bd7efd
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1213550 ms
Total Talk Time (AGENT): 584153 ms
Total Talk Time (CUSTOMER): 367435 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/07/a01aa460-3a64-4661-85c7-190527bd7efd_20250307T16:05_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes ma'am, I just have some questions about um my I don't even know I guess my account.
[AGENT][NEUTRAL] OK, so you're the insured. OK.
[CUSTOMER][NEUTRAL] I'm
[CUSTOMER][NEUTRAL] I am the insured, yes ma'am.
[AGENT][NEUTRAL] Mhm. Uh-huh. And you have questions on or what type of questions do you have?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I don't know. So, uh, because all it's like literally this is like um.
[CUSTOMER][NEUTRAL] Reading French to me, so can I give you my claim number?
[AGENT][NEUTRAL] OK, first off, yes ma'am, I can answer some questions for you, but I'll need to um who am I speaking with first off?
[CUSTOMER][NEUTRAL] OK, this is my name is [PII].
[AGENT][NEUTRAL] I'm so sorry, what's the first name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, Ms. [PII], thank you. And what is a good callback number for you in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, and your policy number, please?
[CUSTOMER][NEUTRAL] OK, my policy number it looks like is 02553638.
[AGENT][NEUTRAL] OK, thank you. So if you'll give me just a couple of moments to get your information pulled up first.
[CUSTOMER][POSITIVE] No problem.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, Ms. [PII], any information that I do provide for you today would be a verification of benefits and not a guarantee of payment. I will have to verify several things with you first for security. So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and your home mailing address please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] [PII] sorry.
[AGENT][NEUTRAL] That's OK. Thank you. The phone number, one of the 2, we have 2 different phone numbers on file for you. What is another number that we could also have?
[CUSTOMER][NEUTRAL] OK, um, I don't know what you have, uh, either the [PII] is not a good number, so.
[AGENT][NEUTRAL] It's not, OK.
[CUSTOMER][POSITIVE] Mhm, so the best number is.
[AGENT][NEUTRAL] Does that need, so that
[AGENT][NEUTRAL] Oh, I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] That's an old
[AGENT][NEUTRAL] OK, so you.
[CUSTOMER][NEUTRAL] That's OK. That's an old landline that we have.
[AGENT][NEUTRAL] OK, so you're [PII] is your best number?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, thank you. And lastly your email address please?
[CUSTOMER][NEUTRAL] Um, info.
[CUSTOMER][NEUTRAL] At
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And I see that you are also set up in our portal, the online service center.
[CUSTOMER][POSITIVE] I am. I'm hoping I'm in the right place.
[AGENT][NEUTRAL] Were you, OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For
[AGENT][NEUTRAL] So I do see that we have 10, I'm so sorry. I don't know what it's the, I don't know if it's the phone. I, I'm not meaning to speak over you.
[CUSTOMER][NEUTRAL] For some reason when I'm
[CUSTOMER][NEUTRAL] No, that's OK that's OK, um, when I pull up, when I like log into my um account, first of all it has my husband's name.
[CUSTOMER][POSITIVE] So we both have this covered years ago so I just, I'm hoping I'm in the right account because when I looked.
[AGENT][NEUTRAL] I don't think
[CUSTOMER][NEGATIVE] When I look at the top, it says my coverage, there's nothing. There's nothing there.
[AGENT][NEUTRAL] OK, so I don't think you're logged into the correct place because there is not any information indicating your husband or, you know, past or present on this policy that you have.
[CUSTOMER][NEUTRAL] So I'm just
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So give me just this.
[CUSTOMER][NEUTRAL] OK, so I think I need to make a new thing.
[AGENT][NEUTRAL] Well, no, it does show that you are, have opted in for text notification alerts. So give me just a moment, Ms. [PII], to look at something.
[AGENT][NEUTRAL] OK, so what user name did you sign in with?
[CUSTOMER][NEUTRAL] So I
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I signed in with info at ASFL, but what I did because we had this, we had gap insurance years ago and then we didn't have it for a while and then I signed up for it just myself this year.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And so when I went in to file a claim I filed it.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Under that old account.
[CUSTOMER][NEUTRAL] And I'm wondering if that was part of my mistake.
[AGENT][NEUTRAL] OK, so the profile that I can see Ms. [PII] for you has the username as [PII]
[AGENT][NEUTRAL] That is for your profile only.
[CUSTOMER][POSITIVE] Oh, I see it here. I have this one saved as well.
[AGENT][NEUTRAL] Yeah, you created that one in December. So that is the one that's just for you and that is the one.
[CUSTOMER][NEUTRAL] That's the one I need to do it there.
[AGENT][NEUTRAL] That I'm looking at.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, OK, well they still put this claim under my account so here I see it I see it now.
[AGENT][NEUTRAL] I did. Mhm. Yes.
[CUSTOMER][NEUTRAL] I see it.
[AGENT][NEUTRAL] We try to do that if we receive it on an old policy number and there is a new policy, you know, policy for the member that's active for, you know, we try to do that internally.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, OK, well that's good, that's good, so.
[CUSTOMER][NEUTRAL] This is my question then now that I'm on the right account, I'm in the right place, um, this paper that I received, first of all, nothing was approved.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] not one.
[CUSTOMER][NEUTRAL] But it says on here.
[CUSTOMER][NEUTRAL] D10082. Please provide a diagnosis code for this date of service. This information may be obtained from your physician.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What am I obtaining?
[CUSTOMER][NEUTRAL] Like I don't even know what what that's referring to.
[AGENT][NEUTRAL] That is for lab work. It shows that you had lab work on [PII].
[AGENT][NEUTRAL] Of [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] OK, so what I really wanted to get covered was my PET scan.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And did I, did I file it incorrectly or is it just not gonna be covered because it's technically done at my doctor's office.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] office visits and procedures done at a doctor's office are not covered under this supplemental policy.
[CUSTOMER][NEUTRAL] OK, so does that mean my PET scans aren't covered because I have them at my doctor's office?
[AGENT][NEUTRAL] Correct. Yes, ma'am. Treatment out of the doctor's office, imaging done at a doctor's office, those things are not, those would fall under office treatment essentially, and that is not covered under your policy. This policy is more for diagnostic testing facilities, hospital, outpatient, free-standing facilities.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So what date did you say that I had lab work?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Um, yes, ma'am. It shows lab for [PII]. That's the one that we were needing the diagnosis code for.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, um, and when you say diagnosis code like my health.
[CUSTOMER][NEUTRAL] Like what's going on with my health or?
[AGENT][NEUTRAL] Yes, the provider, right. That is the why your doctor ordered it. We know that he ordered lab, but the diagnosis is the why it was ordered.
[CUSTOMER][NEUTRAL] What does that mean?
[CUSTOMER][NEUTRAL] OK, why ordered.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But they would know just when you contact them that you're needing the diagnosis code.
[AGENT][NEUTRAL] Related to your lab work that was ordered for [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. Um,
[AGENT][NEUTRAL] You can read that exact remark, you know, that's on your explanation of benefits stating that.
[CUSTOMER][NEUTRAL] OK, so do you, is our labs something you guys even cover? because they're done at my doctor's office.
[AGENT][NEUTRAL] You do have a lab writer? Yes, ma'am. You have a lab writer. Now, um, you do have a lab writer on your
[AGENT][NEUTRAL] On your policy that we can review under. Let me look at the verbiage that's on your policy. Give me just a moment because that may be for an independent lab. So one moment, let me look at that.
[AGENT][NEUTRAL] Uh yes, ma'am. That is for an independent lab facility. It's a laboratory facility that is not a physician's office, hospital, or MRI facility.
[CUSTOMER][NEGATIVE] All right, so basically this policy isn't gonna do me any good.
[AGENT][NEUTRAL] If it sings
[CUSTOMER][NEUTRAL] Unless I go to the hospital.
[AGENT][NEUTRAL] Yes, your outpatient benefits again are related to more of a facility type setting.
[AGENT][NEUTRAL] And there is in your policy in your portal you do also have a copy, Ms. [PII] of your policy information that's in there with the definitions and your benefit amounts, but yes.
[CUSTOMER][NEUTRAL] Where is that?
[AGENT][NEUTRAL] You would click on your policy number.
[AGENT][NEUTRAL] And there's a it's a PDF it'll it should say starting download.
[CUSTOMER][NEUTRAL] Oh it says getting your file.
[AGENT][NEUTRAL] Mhm. Well, OK. I think they paged the verbiage a little bit, but yes, ma'am, that should be it. It's 46 pages.
[CUSTOMER][NEUTRAL] Starting
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] But if you go to, for example, if you were to have, and it does, if you look on your total document pages, not the page numbers that you see on the like the lower right corner of the page, but the total document, your outpatient benefits start on schedule of benefits starts on page 3446.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] And it will give you the different facilities, you know, that fall under your outpatient that we can review for. So that seems like a hospital ER urgent care.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Outpatient hospital, diagnostic testing.
[AGENT][NEUTRAL] It lists them all out.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] All right, so there's really no reason then to get why my doctor ordered this lab work because it was done at his office and it's not gonna cover it anyway, right?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] If it was not done at an independent lab facility, yes, and that is not covered under this policy.
[CUSTOMER][POSITIVE] OK, alright, so then this is all for nothing. OK, alright, well thank you for your help. I appreciate it.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Well
[CUSTOMER][NEUTRAL] I guess there's no way I can fight this, right?
[AGENT][NEUTRAL] You're welcome, Ms. [PII]. Is there anything else I can help you with?
[AGENT][NEUTRAL] You can always file an appeal within 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] No, that's it.
[CUSTOMER][NEUTRAL] I know, but is that gonna do any good?
[AGENT][NEUTRAL] And you
[AGENT][NEUTRAL] I can't, I can't advise on that. I can only tell you that you, that is your right to file an appeal.
[AGENT][NEUTRAL] And it would need to be, must be filed within that 180 day period from the date of the decision which was on [PII].
[CUSTOMER][POSITIVE] So if I decided to do that, how do I do that? I can do it online?
[AGENT][NEUTRAL] You can. It would need to be submitted to attention appeals department and include any information that you would like to be considered.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right well thank you so much.
[AGENT][POSITIVE] Well, you are certainly very welcome and again if that is all that I can help you with, thank you for calling APL and I hope you have a great weekend.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Yes, ma'am. Thank you.
[CUSTOMER][NEUTRAL] Bye uh huh bye bye.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Are you still there?
[AGENT][NEUTRAL] Uh, yes, ma'am. I am. Oh yes, for I was just about gone, but yes, ma'am, I am.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] So I'm sorry, so I just was looking through here.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] On page this is page 3. It says page 3.
[CUSTOMER][NEUTRAL] But I think it's page 21. Anyway.
[CUSTOMER][NEUTRAL] So it says on here um.
[CUSTOMER][NEUTRAL] Cancer outpatient treatment writer, is that a part of my policy?
[AGENT][NEUTRAL] It is, yes, ma'am.
[CUSTOMER][NEUTRAL] OK, so, so, so I do have cancer. So does that cover any of these treatments that I'm doing at my doctor's office?
[AGENT][NEUTRAL] Let's see, let me get back.
[AGENT][NEUTRAL] OK, so cancer treatment can be considered at the, what it's done at the physician's office as well. Now, we will have to have all the information related to the cancer diagnosis.
[AGENT][NEGATIVE] Um, your cancer, if you want to, instead of me reading all of this to you.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] Because it says here, so in section 3 under.
[AGENT][NEUTRAL] This does say,
[AGENT][NEUTRAL] Yes, but if you come down under your specific rider.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] That would be on page 35 of 46.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] 35.
[AGENT][POSITIVE] It states cancer benefits, we will pay the out of pocket amounts for cancer treatment performed in a cancer treatment facility.
[CUSTOMER][NEUTRAL] OK, so that's where I go.
[AGENT][POSITIVE] It gives you the definition of your writer.
[AGENT][NEUTRAL] So we would, we can review.
[AGENT][NEUTRAL] You do have that benefit on your policy and that would fall under your outpatient benefits yearly calendar year max of $2250.
[CUSTOMER][NEUTRAL] OK, so then.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, so if, if I have a cancer.
[CUSTOMER][NEUTRAL] Outpatient treatment writer.
[AGENT][NEUTRAL] This is for your cancer treatment. Mhm.
[CUSTOMER][NEUTRAL] Right, which is why I have PET scans because I have cancer. So.
[AGENT][NEUTRAL] It's just for your
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I think I am going to.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] I'm gonna see how I can at least.
[CUSTOMER][NEUTRAL] Try to fight this somewhat because I feel like I should be covered.
[CUSTOMER][NEUTRAL] Because of that writer.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] And on your cancer, let's see. I'm still looking at some information related to that. Just a moment.
[AGENT][NEUTRAL] OK. Under your definition of cancer treatment, it says the treatment of cancer at a cancer treatment facility. For the purpose of this certificate, this does not include supplies or drugs recommended or purchased for the use outside of cancer treatment facility or routine visits designed to diagnose or prevent the reoccurrence of cancer.
[AGENT][NEUTRAL] And then cancer treatment facility is defined as a facility where the treatment of cancer is provided on an outpatient basis. This also includes the physician's office. Again, that is for the treatment itself.
[CUSTOMER][NEUTRAL] OK, so what page are you on?
[AGENT][NEUTRAL] Um, that part that I just read would be on page 22 of 46.
[AGENT][NEUTRAL] It gives the definition of cancer treatment and cancer treatment facility.
[CUSTOMER][NEUTRAL] I need to
[CUSTOMER][NEUTRAL] Uh,
[AGENT][POSITIVE] All of the definitions for the different terms just so that makes it a little easier, Ms. [PII] there in alphabetical order.
[CUSTOMER][NEUTRAL] Right. But it does say this includes a physician's office.
[AGENT][NEUTRAL] When you're looking at the ball.
[AGENT][NEUTRAL] For treatment, for the treatment of cancer.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you're, so are you saying?
[AGENT][NEUTRAL] It states on here that this, right, this is routine visits designed to diagnose or prevent the reoccurrence of cancer.
[CUSTOMER][NEUTRAL] It would have to be like a chemotherapy treatment or.
[AGENT][NEUTRAL] It says it does not include that. If you look under the cancer treatment diagnosis um definition rather, I'm sorry, cancer treatment definition.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But again you do have that 180 days, Ms. [PII] for you to file an appeal if you would like for it to be looked at and reconsidered and then again you can include any additional information.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That you would like to have them to look at.
[AGENT][NEUTRAL] Just make sure to put it to attention appeals department so that it doesn't get, you know, received and misunderstood as a duplicate of a previously submitted claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You know
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] OK. Well, yes, ma'am. You're very welcome. Is there anything else?
[CUSTOMER][NEUTRAL] Um, I don't think so.
[AGENT][POSITIVE] OK, Ms. [PII]. Well, if you have any other questions come up, just give us a call and we'll be happy to help you.
[CUSTOMER][NEUTRAL] OK, let's
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] You're very welcome. And again, have a wonderful weekend.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Yes, ma'am. Thank you. Bye bye.