AccountId: 011433970860
ContactId: ad36be99-7128-4403-8eee-8a28dfbc8aca
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1122709 ms
Total Talk Time (AGENT): 333582 ms
Total Talk Time (CUSTOMER): 588541 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/03/ad36be99-7128-4403-8eee-8a28dfbc8aca_20250603T13:55_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], uh, it's [PII]. How are you doing today?
[AGENT][NEUTRAL] I'm fine thanks how are you?
[CUSTOMER][MIXED] I am fine and [PII]. Um, I have an insured with his wife, or insured and her husband who was diagnosed with cancer and they're at a
[CUSTOMER][NEUTRAL] I guess a medical facility. They want to know exactly what we would need in order to process his claim for his uh cancer diagnosis.
[CUSTOMER][NEGATIVE] And I'm trying to look through all the information they sent because one has over 600 pages, another has 30 and one has 13 and I cannot find.
[CUSTOMER][NEUTRAL] The pathology report that she is saying cause it looks like we uh process is needed the initial path report.
[CUSTOMER][NEUTRAL] But it looks like they also had a scan done. She said that is how they found that he had kidney cancer.
[CUSTOMER][NEUTRAL] And then they had the kidney removed.
[CUSTOMER][NEUTRAL] Anyway, um, the policy number is 2403166.
[AGENT][NEUTRAL] OK. So is she saying that they did not have a biopsy, pathology report?
[CUSTOMER][NEUTRAL] Right. That there was no biopsy that they did a scan and that detect the cancer and then they had the kidney removed.
[CUSTOMER][NEUTRAL] And I'm trying to look and see but I can't see anything.
[CUSTOMER][NEUTRAL] I can see some stuff, but it's just a lot.
[AGENT][NEUTRAL] OK, so you just want me to tell them what we need to file their for their claim?
[CUSTOMER][NEUTRAL] Yeah, she wants to know exactly what information we need.
[AGENT][NEUTRAL] OK, I'll go ahead and I'll help them. Um, what's the callback number?
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] And you're gonna hear a lot of voices. It's the insured, uh, her husband, and the.
[CUSTOMER][NEUTRAL] I guess the lady at the hospital that is trying to help them.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] Awesome thank you ma'am have a great one.
[AGENT][NEUTRAL] You too.
[CUSTOMER][NEUTRAL] Do you have to
[AGENT][POSITIVE] Thank you for holding, this is [PII].
[CUSTOMER][NEUTRAL] Hi [PII], I have you on speakerphone. This is [PII]. I'm an oncology clinic social worker and I have [PII]'s wife [PII] here, and we're trying to sort out what, what specifically what missing documentation you guys need for whatever she filed previously and then the second piece of that is this is the week the last week she has to submit something for um.
[CUSTOMER][NEUTRAL] Uh, the denial, the claim denial, and so we needed to know where to fax that and what needed to be included in that, but the first thing is if you could look through the records to see what's been submitted and what is still lacking.
[CUSTOMER][NEUTRAL] So that she knows specifically what to submit.
[AGENT][POSITIVE] I sure I can help you with that.
[AGENT][NEUTRAL] Um, so looking through the claim that was processed, um, it looks like we requested a copy of the initial pathology report that verifies the diagnosis of internal cancer.
[CUSTOMER][NEUTRAL] OK, I think that y'all are calling it a pathology report and [PII]'s health is calling it a pathology consultation service document.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] They, they, nothing they none of their stuff says pathology report on it even when I asked for a pathology report, this is what they did that's gonna be what it is.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right. Uh, I mean, it doesn't have to necessarily say pathology report. It would just need to be the lab results from when a biopsy was taken and where they diagnosed the internal cancer.
[AGENT][NEUTRAL] Is the documentation that we're reviewing.
[CUSTOMER][NEUTRAL] OK, so I don't
[CUSTOMER][NEUTRAL] Then I may not have given you that you may not have that so we are holding a document here that says pathology consultation services and it's talking about um the the specimen being gathered and lots of medical language and um.
[CUSTOMER][NEUTRAL] It it's, uh, I, I thought that y'all wanted the pathology report from when we I thought y'all's goal was to find out what was the first day that anybody ever knew anything about that cancer, that kidney cancer, and I thought that I had to, OK, so how can we, if we send this to you, will this suffice the pathology consultation services and this is dated [PII].
[CUSTOMER][NEUTRAL] That's when they collected.
[AGENT][NEUTRAL] Right, so
[CUSTOMER][NEUTRAL] And it diagnosis right kidney ne nephrectomy. I mean, I guess that's what they did, yeah, it, it's a complete pathology report that was part of his medical record.
[AGENT][NEUTRAL] Right, so that's what we're needing to confirm. First we need to confirm the actual diagnosis and confirm when it was discovered so that we know when the claim begins. So yes, that's the documentation that was requested.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, on this report, I don't know if it says when it was discovered. It says when it was, but I've already sent y'all the [PII] because that's when it was discovered. So that, that one should be, but it was, it was discovered and suspected, and then this pathology report confirms it. That's right.
[CUSTOMER][NEUTRAL] So you need the confirmation of it.
[AGENT][NEUTRAL] I'm sorry, say that again. It, it was discovered when?
[CUSTOMER][NEUTRAL] [PII], he was, he was in the hospital at [PII] and it sounds like subsequent to that that this is the pathology report that resulted from that because this was done in [PII].
[AGENT][NEUTRAL] OK, so there was no discovery in [PII]?
[CUSTOMER][NEUTRAL] No, not of this cancer. There was not. This cancer, no one knew existed. He never even had a symptom. It was by a fluke they found it and they found it on [PII].
[CUSTOMER][NEUTRAL] So yeah there's two different.
[AGENT][NEUTRAL] OK, and so, and that's when the biopsy was done was in December?
[CUSTOMER][NEUTRAL] Uh, no, I think it was done [PII], but on [PII] is when they did the imaging and saw that his whole kid, almost the entire kidney, was not even identifiable because of a huge mass.
[CUSTOMER][NEUTRAL] That was [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so yes, if you can provide the copy of that, the imaging results, those lab results from [PII], um, I'm sorry, [PII] and then the biopsy in February, um, yes, then we, we can review that.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] I've got the biopsy results in my hand from February, but I think you already have the [PII]. I think you already have that thing.
[CUSTOMER][NEUTRAL] So was that a hospital stay that we, we had gone into the emergency room and he ended up he did have a hospital stay.
[CUSTOMER][NEUTRAL] So that's been submitted.
[CUSTOMER][NEUTRAL] By you to them, yes, OK.
[AGENT][NEUTRAL] OK. And so what imaging was that in December?
[AGENT][NEUTRAL] That detected the cancer.
[CUSTOMER][NEUTRAL] Um, you know, I don't.
[CUSTOMER][NEUTRAL] I don't know if it was a CT or an MRI. I don't know what it was.
[AGENT][NEUTRAL] OK, bear with me just a moment please.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Oh, OK, this was [PII], right?
[CUSTOMER][NEUTRAL] Yeah, so she's
[CUSTOMER][NEUTRAL] She this was where they're telling us we got it.
[CUSTOMER][NEUTRAL] I it's the same.
[CUSTOMER][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] Uh, there's another one in here that makes us know for sure they got it because they wrote a little letter that said we received and this was.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And I thought you said it was found in his kidneys?
[CUSTOMER][NEUTRAL] Yeah, right now we're talking about his kidney cancer, yes.
[CUSTOMER][NEUTRAL] The kidney cancer that was in the kidney.
[AGENT][NEUTRAL] OK, so I do see the results from looks like a CT scan done on [PII].
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um, and so, this information, it does not confirm a positive diagnosis of cancer.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right. OK, so I think you need.
[AGENT][NEUTRAL] So it would need to be the actual um diagnosis, uh actual results from the pathology that we would need.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can we, where can we can we we can fax, I can help her fax that from here. What is the best fax number and how, how, where does it get routed to?
[AGENT][NEUTRAL] Sure, our fax number is [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what does it need to contain on it like so that it gets routed to the right account and everything?
[AGENT][NEUTRAL] You can attention it to the claims department.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I would have the policy number somewhere visible on the cover page, um, and the policy number is 2403166.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 3166 OK.
[CUSTOMER][NEUTRAL] So that sounds like that would take care of what you guys need and then our my second question had to do with.
[CUSTOMER][NEUTRAL] The appeal she's got this week to do the appeal. What format like is it it just need to be a typed letter and where does that get sent to the same place or different place?
[AGENT][NEUTRAL] Oh, what claim is the appeal for?
[CUSTOMER][NEUTRAL] Um, for this, this one that we're doing right now, we're talking about the same one she sat down to look at it with me just now, and while we were looking we found that at the bottom of one of the documents she sent me it said that I had 180 days to appeal to to um appeal the claim and I did I didn't know I had to do that and so we, we wanted to know how to do that.
[AGENT][NEUTRAL] OK, so, um, I mean, it's completely up to you if you want to file the appeal, uh, the appeal is more for like a claim decision like if your claim was completely denied, um, we're not denying your claim, we're just needing additional information.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, well we can.
[AGENT][NEUTRAL] I mean, that's completely up to you if that's what you wanted to do, like if you were wanting to appeal, cause pretty much you would be appealing our decision to request the pathology report, but you're saying you're about to send the pathology report, so.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yeah, it was a moot point.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, we will do what do you want to do? OK, so we will send you, we're gonna fax to you this documents and um could somebody call us back and uh or or um.
[CUSTOMER][NEUTRAL] Send me an em[PII], an email would be great saying we received it, uh, I mean, and letting me know if you still need further information on this claim.
[AGENT][NEUTRAL] OK, so how it would work is that once we receive the fax, um, I would give it about 48 hours to for the fax to be received and uploaded into the claim. Um, you, you're free to give us a call within the 2 I mean 48 hours to see if it had been received, um, and then our processing time is about 5 to 10 business days from the date of receipt, and then you will receive an updated response from us once the claim has been reviewed and processed.
[CUSTOMER][NEUTRAL] OK, and so I, I'm, I'm not sure how this works. Do I need to.
[CUSTOMER][NEUTRAL] Submit like we scans like every time he's had an MRI every time he's had a CT scan, do y'all pay individually on things or is there some sort of, or is it like a lump for a surgery? Uh, how, how do I make sure I claimed on everything I should have?
[AGENT][NEUTRAL] Sure, do you happen to have a copy of your policy certificate or do you know how to view it online on your online service center account?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] I don't know that I have one and I'm not positive how to view that. Uh, I do have a thing that says [PII], so I guess that's where I would go to get, you know, and I have been on the site, but right offhand I don't remember the.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, yes, so like when you go in the online service center, um, when you're when you're submitting in your claim because I see we've received a few claims from, um, uploaded online, when you go to that to that site, um, there is where you can click on, um, to view your policy certificate.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, it was on that policy number, um, it's like before you go to like actually submit the claim, and it will have like in that policy certificate it'll have the schedule of benefits in there and it lists out every single benefit that's payable under your policy, um, so that's how you can kind of see what is, what is payable. So for like your imaging benefit like you said for that, the PET scan, MRI or CT scan.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, it'll show you that it pays one test per calendar year.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So each benefit it'll kind of list out, you know what's payable, how much it pays, and how often you can claim it, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] In that benefit schedule mhm.
[CUSTOMER][NEUTRAL] OK, and then, um, for the one time $7500 is that one time for cancer, one time per year, one time for what?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] For the internal cancer first occurrence writer, the $7500.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. Yes, that is for the initial diagnosis. So that's why we were needing to verify that the pathology report, and it's only payable once per covered person per lifetime of the policy. It's basically once you've been diagnosed with cancer, it pays that lump sum and then that's the only time that it will be payable for the lifetime of the policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, alrighty, alright, I'll go and try to see, uh, so, so once I see the list and it says um one MRI per year, then I just find one of the MRIs he had for that year and submit it.
[AGENT][NEUTRAL] Yes, and it would be, you know, after the diagnosis of cancer has been confirmed.
[CUSTOMER][NEUTRAL] OK, so an MRI after the like after, so after any time anything after [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Because that's when it was confirmed through the pathology and then what, what do you need? Is it just you just need a bill that says that he had it done on that date or what do you need?
[AGENT][NEUTRAL] Yes ma'am, we can either use an itemized bill or if you also have the explanation of benefit from his primary insurance carrier, we can accept that as well.
[CUSTOMER][NEUTRAL] You said an automized bill or a what like the explan it the you know, being a statement you get from your uh insurance that says this is what we paid and this is, you know, this is a procedure and this is what we paid and either one of those will work.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] OK, alrighty.
[CUSTOMER][NEUTRAL] Anything
[CUSTOMER][NEUTRAL] I, I'm kind of just inserted in here so I'm trying to do catch up, educate myself catch up, but it sounds like basically that the essential thing is for me to just fax that pathology report right now and we can do that. That's not a problem.
[CUSTOMER][NEUTRAL] OK, and then
[CUSTOMER][NEUTRAL] And then, and then after that he didn't he, he's ended up he's had another cancer but since you're, since you won't do the 7500 again, I will just look for the test off of the list that uh policy certificate. I will just look for tests they're on there but you still will need.
[CUSTOMER][NEUTRAL] The path will you need the pathology report again of, of the, the new cancer which is also again renal, the renal carcinoma or whatever but it's just moved into a different part of his body.
[AGENT][NEUTRAL] Uh yes, if it did metastasize, then yes, I would provide that update as well, um, because that could um potentially incur additional treatment and we need to be sure of exactly what type of, what type of treatment he's receiving.
[CUSTOMER][NEUTRAL] So do you are you are
[AGENT][NEUTRAL] That it matches with his diagnosis. So if the diagnosis changes, we just wanna be sure that our system is updated with that information as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, well we'll finish this one first and then we'll move on to the more current one yeah.
[CUSTOMER][NEUTRAL] OK, you, you haven't.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, well we appreciate your time and um we will get that faxed here in the next couple minutes.
[AGENT][POSITIVE] Uh yes ma'am, is there anything else I could do to help you today?
[CUSTOMER][POSITIVE] No thank you I appreciate your time thanks a lot.
[AGENT][POSITIVE] Sure, thanks for calling APL. I hope you have a good day.
[CUSTOMER][NEUTRAL] You too
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Sorry