AccountId: 011433970860
ContactId: a69d2b6d-6031-4fb1-a266-689ac359404b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1503469 ms
Total Talk Time (AGENT): 544684 ms
Total Talk Time (CUSTOMER): 481776 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/a69d2b6d-6031-4fb1-a266-689ac359404b_20250117T16:19_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Um, well, I have some, uh, questions about my claim.
[AGENT][NEUTRAL] OK, well I can help you with your claims questions. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, uh, [PII] [PII].
[AGENT][NEUTRAL] Thank you for that, Ms. [PII]. May I have your policy number?
[CUSTOMER][NEUTRAL] Um, yeah, just talking, please.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Policy number is 02548800.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify your date of birth, your mailing and email address on file?
[CUSTOMER][NEUTRAL] [PII]. My address is [PII] and my email address on file is [PII] uh.
[CUSTOMER][NEUTRAL] [PII] and if it's not that one it's my personal one, [PII].
[AGENT][POSITIVE] Alrighty, and thank you so much for verifying your information and all the information provided is a verification of benefits, not a guarantee of payment. And how may I help you with your claims questions?
[CUSTOMER][NEUTRAL] Well, uh, I'm looking at the
[CUSTOMER][NEUTRAL] Website on, it says, you know, um.
[CUSTOMER][NEUTRAL] Whatever claim I have submitted.
[CUSTOMER][NEGATIVE] My husband is deceased. That's the um the claims are for my husband. He was diagnosed with cancer.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, in September.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, he, um,
[CUSTOMER][NEUTRAL] He had only 11 treatment because he died after that.
[CUSTOMER][NEUTRAL] He only had one treatment. He had the immunotherapy uh treatment at Dallas, um, at the Dallas hospital.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And he died from a stroke.
[CUSTOMER][NEUTRAL] I have submitted all the papers that they asked me to submit.
[CUSTOMER][NEUTRAL] And the only thing that I see here that they are
[CUSTOMER][NEUTRAL] Actually paying is $50.
[CUSTOMER][NEUTRAL] For the
[AGENT][NEUTRAL] X-ray.
[CUSTOMER][NEUTRAL] It says
[CUSTOMER][NEUTRAL] It says,
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] 4.
[CUSTOMER][NEUTRAL] The diagnosis, I guess, just a minute, so I can tell you what it says.
[CUSTOMER][NEUTRAL] It says diagnosis, diagnostic testing.
[AGENT][NEUTRAL] So you're wanting to know why only $50 was applied to the claims that were received?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK. So I looked through all the claims that we processed for him, the $50 preventative, um,
[AGENT][NEUTRAL] Amount, that's the max for um like preventative testing. The other uh codes were denied either because, well, one of them, the charges submitted are not covered by the policy contract. So on the, do you have the explanation of benefits there with you for each of the claims that were submitted?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Ma'am, I, I submitted tons of paperwork because they told me I needed an EO I'm, I'm gonna tell you everything that they told me I needed to, and I went to the hospitals, at UVO I needed a um
[CUSTOMER][NEUTRAL] Uh, itemized bill for any hospital stays. I needed a, um, all of this that is here, that when I talk original to the person, uh, [PII], I don't know, but that's what's the name of the person, uh, she told me to, to get all the, the stuff. When I went to the hospital, I told them when my husband was in the hospital from what day to what day.
[CUSTOMER][NEGATIVE] And that's what they gave me. They gave me a UVO 4 for the days that he was in the hospital in uh [PII], and then the one in [PII] where he died.
[CUSTOMER][NEUTRAL] Um, I submitted all the paperwork.
[CUSTOMER][NEUTRAL] I did, I mean, there was things in there that probably didn't apply to you, but that's what they gave me. So, in that paperwork.
[AGENT][NEUTRAL] Right, but I'm asking.
[AGENT][NEUTRAL] The question that I'm asking you though is if you have the explanation of benefits from us for these claims, there's a reason I'm asking that.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] The reason I'm asking that is because on the 2nd page of each explanation of benefits, it gives you a detail of each of the reasons. So I was wondering if you had that, but basically the other services are not covered by the by the policy. So that's why they
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So, the treatment that he got at the hospital for the cancer is not, is not um covered.
[CUSTOMER][NEUTRAL] The fact that he had, he died from a stroke, and this is a policy for cancer and stroke, is also not covered.
[CUSTOMER][NEUTRAL] Is that what you're telling me?
[AGENT][NEUTRAL] That's what I'm telling you for some of them, but there's several different reasons. That's why I was wondering if you had the explanation of benefits so you can see them all. However, if you like, I can go through them with you, so you, some of them were denied.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Oh yes, I would love for you to go through through that with me because I will cancel my my policy for myself if that's the case.
[AGENT][NEUTRAL] Some of the claims, some of the um claims were denied requesting additional information, so we can go through it together, but I was just wanting to let you know that that's what the reason was for some of them.
[AGENT][NEUTRAL] Would you like to go through the claims together?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] So he has one.
[AGENT][NEUTRAL] Two claims altogether. So claim number 354-8145.
[AGENT][NEUTRAL] The preventative um testing was paid for $50 so that's like the X-ray there. Then you have an ambulance charge, a hospital charge.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Another preventative charge and it looks like the first occurrence heart attack and stroke. So for the first occurrence benefit for heart attack and stroke,
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] This was denied stating based on the effective date of coverage, it's necessary that we obtain the medical records. So it's, it's not denied as in we won't pay, it just needs the medical records because we have to see if it was a pre-existing condition. So they're asking to complete the claim form and then um we can request the records from the doctor. So that's why that was denied. Once the records are received, we can continue processing.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] The other codes on here?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, where is the form?
[AGENT][NEUTRAL] Um, it was
[CUSTOMER][NEUTRAL] That I have to tell you
[AGENT][NEUTRAL] It was sent with the explanation of benefits, but I can reach out to claims and get a form for you and see if I can email it or mail it to you. Um, would you prefer it to be emailed if I can?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK, so I'll reach out to claims for the claim, uh, for the form. Hold on, let me make a note.
[CUSTOMER][NEUTRAL] And when you talk about existing pre-existing condition, what was the pre-existing condition that they think he had? Or the one that they want to find out?
[CUSTOMER][NEUTRAL] The cancer itself?
[AGENT][NEUTRAL] No, this
[AGENT][NEUTRAL] So this is just saying they have to look, so on the effective date, let me see, hold on one moment, let me go back.
[AGENT][NEUTRAL] So the policy has been effective since [PII]. So anytime there's a first occurrence of anything, whether it's cancer, heart attack, stroke, any type of first occurrence, we have to ask for medical records so that we can then see if it was before the effective date or after. That's just something we have to do by law. So that's why we're asking that.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, um, I'm gonna get that form for you, uh, and if they can, if I can email, I'll go ahead and email it, but if I have to mail it, I'll, I'll um have it mailed to you, but I'm gonna check and confirm before we're off the phone, so you know which way it's going to be sent.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] OK, because they sent me a letter uh saying something like that, but there was no phone with the letter. It was only, I, I would read it to you because I just got it not to a couple of days ago.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me, let me get that, please.
[AGENT][POSITIVE] OK, take your time.
[CUSTOMER][NEUTRAL] OK. The, the letters that they send me.
[CUSTOMER][NEUTRAL] Just a couple of days ago or whatever. So we received a claim on your policy and review the claim has started. In some cases additional information might be requested from your provider of medical service for the claim to be processed, but that's all they sent. I haven't received a form. I haven't received anything else.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I'll let them, I'll get that form for you. So, um,
[AGENT][NEUTRAL] The other denial reasons, OK, losing my spot. Hold on one second.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so that's the same for that one and that one we already did this one. Let me see what this one is.
[AGENT][NEUTRAL] There's 2 on here that are not covered. It's for the procedure though it says air, so I'm not.
[AGENT][NEUTRAL] Sure what that is, um.
[AGENT][NEUTRAL] And then let me see what.
[AGENT][NEUTRAL] Is there any other one that we didn't go over?
[CUSTOMER][NEUTRAL] For the procedure, I don't know, are they talking about the biopsy?
[CUSTOMER][NEUTRAL] Because she told me to get the, the information for the biopsy, and she told me to, to get the, the pathology report. She told me to get the diagnosis of cancer, and she also told me to get all the information of the day when he had the stroke.
[CUSTOMER][NEUTRAL] And I have sent all those paperwork. I have the confirmation number.
[AGENT][NEUTRAL] Well, we've received it. We've received everything and the claim has been processed. Um, let me see if this is for the biopsy. Hold on one moment.
[CUSTOMER][NEUTRAL] Because I affected everything.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEGATIVE] The reason there's a bunch of other stuff is because that's all what they gave me at the hospital altogether. They didn't want to give me just for a specific thing. They gave me the whole thing.
[AGENT][NEUTRAL] Yes, there's not
[CUSTOMER][NEUTRAL] And I'm not a doctor, so I couldn't, I couldn't tell which one is the one that you wanted or not, so I sent everything that I have.
[AGENT][NEUTRAL] I understand there's nothing wrong with what you sent in. I'm just trying to get you the reasons.
[AGENT][NEUTRAL] Well, the reason that the $50 was paid out is because that was, that's the amount that's paid for your preventative testing, and then you know that the other ones were uh denied waiting for the
[AGENT][NEUTRAL] Um, request for medical records and then there were a few on here that were not covered. Um, there's, let me see if this is the same date. Yeah, there's no surgery benefit on the um policy, so that's why the other three codes were denied. So there's no surgery benefit. We need the medical records.
[AGENT][NEUTRAL] And then,
[AGENT][NEUTRAL] The others were paid out on for the preventative testing.
[AGENT][NEUTRAL] But once we get the
[CUSTOMER][NEUTRAL] OK, and, and when you talk about surgery, which one are you talking about? I mean, the biopsy is not really a surgery, it's just a, a procedure.
[AGENT][NEUTRAL] Well, the procedure and a surgery is the same thing. So it's coming in, it's based off the codes. So there's no surgery benefit for this policy. So any type of surgery or procedure would be not covered.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But for the
[CUSTOMER][NEUTRAL] So I guess she just wanted me to send that so they, you know, that they did a biopsy? Because I mean, I have a list of things that she gave me. And one of those things was a biopsy.
[AGENT][NEUTRAL] Well, we're not
[AGENT][NEUTRAL] So we're not claims examiners here on the care team. So she told you to send everything in so that once it is examined, if, if this was processed and they needed the information for the biopsy, then it would be denied requesting that information. So she just told you to send everything so that you don't have to send anything.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Else in terms of the services he received. This asking for the medical records, you wouldn't have known to send that and we wouldn't have known that they need it because we don't examine the claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, on the APL um website where I have my account when I open it, the one that they're denying it says at the bottom explanation of benefits, and it says please complete the enclosed form and return to our office, but there's no form attached to it.
[AGENT][NEUTRAL] Right, so that's, yes, that's the form that I'm gonna get for you. We, um, so that's what I was asking if you had the explanation of benefits, but you already told me that you didn't have the form, the form wasn't there, so that's, I'm talking to claims now to get that form for you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome. And do you mind if I place you on just a brief hold so I can see if this is the form I can get or if they need to send it to me?
[CUSTOMER][NEUTRAL] OK, thank you. Yes, that's fine.
[AGENT][NEUTRAL] You're welcome. Hold on one moment.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Um, I'll go to ours first, I guess.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I'll check again.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII] on the care team. How are you?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] I'm doing good. I don't need to transfer anything. There's just a member, she needs a um a claim was processed. We're asking for her to fill out a form for medical records, but there was no form attached. How do I get that?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What's the policy number?
[AGENT][NEUTRAL] It's 254-8800.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm, but it's for part two.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh yeah, that should have went with.
[CUSTOMER][NEUTRAL] Excuse me, I should have went with the EOB. It's a list of attending physicians form.
[CUSTOMER][NEUTRAL] Let me see.
[AGENT][NEUTRAL] I'm going to check back with her, OK? Hold on one sec.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello [PII]?
[AGENT][NEUTRAL] Hello, [PII].
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, I think she might have me on hold.
[CUSTOMER][NEUTRAL] Yeah, um, we would have to send her another one.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because I'm not sure I know it's not on the website, it's one of the templates we have. So if you wanna send her over or I can um.
[CUSTOMER][NEUTRAL] Generate one and send it to you. How do you wanna do it?
[AGENT][NEUTRAL] Um, you can, you can generate it and send it to me because she's a little, she's, she's borderline upset, so I don't want any other, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Got it. I wanna to pass her on and then she's even more frustrated. OK, that's no problem. So what I'm gonna do is um
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I can email it to you.
[AGENT][NEUTRAL] Are we allowed to email them to the insured? OK, because she asked for email. OK, so I'll just email it to her when you email it to me.
[CUSTOMER][NEUTRAL] Yeah. Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK. I'm gonna get that done right now and look out for it in a few minutes.
[AGENT][POSITIVE] Alrighty, thank you, [PII].
[CUSTOMER][POSITIVE] OK, no problem. All right, bye.
[AGENT][NEUTRAL] All right, bye bye.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Hey, thank you so much for holding. I apologize for that wait. So I did speak with the claims examiner. She's um generating the form and emailing it to me and then I'll email it to you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So you should have that by the end of day today. She's doing it right now, so I I should have it to you within an hour, but I'm just saying in the day to be on the safe side, um, and then I'll go ahead and email it to you and once we get it back, we'll continue processing for that first occurrence, um, for the heart attack and stroke.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] OK. Well, first, I do want to say um we're so sorry for your loss. If you need anything, let us know. And was there anything else I can help you with?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, um, after I send the form, uh, when can I check with you to see how what's the status and what if we, if you need anything else?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] After you send the form, I would give it at least a week, um, because it's 7 to 10 business days, but we already have everything else. That's the only thing they were waiting for, so I don't know if that makes it shorter or not. So I would just say that 7 to 10 days just to be on the safe side.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Alrighty. Well, was there anything else I can help you with? Oh, and you know what, hold on, before we go, I know we are already um
[AGENT][NEUTRAL] Confirmed it, but I just, I'm gonna be sending the email when we're off the phone, so I just want to make sure. So you want to send it to the [PII]?
[CUSTOMER][NEUTRAL] That's fine.
[AGENT][NEUTRAL] OK, so I'll send it to that email and it'll be coming from the care team.
[CUSTOMER][POSITIVE] OK. Thank you, ma'am.
[CUSTOMER][NEUTRAL] Care team, OK.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] All right.
[AGENT][POSITIVE] All right. Well, thank you so much for calling APL. You're welcome and have a good weekend.
[CUSTOMER][POSITIVE] OK, thank you very much.
[CUSTOMER][POSITIVE] You too. Thank you. Mm bye-bye.
[AGENT][POSITIVE] You're welcome. Bye bye.