AccountId: 011433970860
ContactId: afd54aa3-7f98-479c-9996-3f68ad3b9935
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1475359 ms
Total Talk Time (AGENT): 524801 ms
Total Talk Time (CUSTOMER): 326434 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/24/afd54aa3-7f98-479c-9996-3f68ad3b9935_20250624T18:22_UTC.wav
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[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Thank you for calling APL. This is Sa[PII]How can I help you?
[CUSTOMER][NEUTRAL] Uh, yes, ma'am. I was trying to, uh, check on my claims, uh, named Ca[PII].
[AGENT][NEUTRAL] OK, Ca[PII]I'm happy to check on some claims. Do you by chance have your policy number?
[CUSTOMER][NEUTRAL] Uh, give me one second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yes, ma'am. Are you ready?
[AGENT][NEUTRAL] Yeah, go ahead.
[CUSTOMER][NEUTRAL] It is C0909458.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Our job.
[AGENT][NEUTRAL] And it starts with a C as in Charlie?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] Be progressive type.
[AGENT][NEUTRAL] And you said your last name is Ma[PII]?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] What state do you live in?
[CUSTOMER][NEUTRAL] Uh, I live in Mi[PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then date of birth?
[CUSTOMER][NEUTRAL] 92[PII]
[AGENT][NEUTRAL] [PII]nd then if you could just verify the address with me.
[CUSTOMER][NEUTRAL] 24[PII].
[AGENT][POSITIVE] Thank you, Ca[PII]OK, so looks like.
[AGENT][NEUTRAL] You have a couple different policies with us. Was it filed under the accident, critical illness, which one was it?
[CUSTOMER][NEUTRAL] Uh, it was, it was both because, um, the way that I was going about it, um, and the way that, uh, it was set up, I know 11 of the policies told me to uh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, the file for um my bone marrow biopsy.
[CUSTOMER][POSITIVE] So I did that, then I think I did like uh the cancer policy and I did like the critical illness.
[CUSTOMER][NEUTRAL] To see, you know, which one, my.
[CUSTOMER][NEGATIVE] Situation will fall under.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Cause I couldn't get, you know, a direct answer on like which one I should file so I just did all of them to see, you know, which one.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] was uh gonna cover it.
[AGENT][NEUTRAL] Gotcha. OK. Um.
[AGENT][NEUTRAL] So the critical illness claim was processed yesterday. It looks like we need an itemized bill or medical record.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] It's just.
[CUSTOMER][POSITIVE] That was great.
[AGENT][NEGATIVE] It was denied.
[AGENT][NEUTRAL] But it's just asking for an itemized medical bill to be submitted.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] So I will have to get that from the doctor. I mean the doctors filled the form out for me.
[CUSTOMER][NEUTRAL] So I'm not.
[AGENT][NEUTRAL] Yeah, you would need to get it, yeah, you would need to get it from the provider. You could contact them and just let them know that for your insurance, you need an itemized bill.
[AGENT][NEUTRAL] For consideration on a medical claim.
[CUSTOMER][NEUTRAL] OK, so the form that I fill out, I mean, it, it wasn't valid for anything?
[AGENT][NEUTRAL] The form was valid, I believe, as far as what you had submitted. I don't see anything wrong with the form. They're just asking for um a medical bill.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And this is for the critical illness.
[AGENT][NEUTRAL] Mhm, that's for the critical.
[CUSTOMER][NEUTRAL] Or would I have to do one for the uh the biopsy or?
[CUSTOMER][NEUTRAL] I mean,
[CUSTOMER][NEUTRAL] I'm trying to understand cause if the claim was rejected, I mean, I'm calling but I didn't get any information pertaining to why, you know, it was rejected.
[AGENT][NEUTRAL] So I can send you.
[AGENT][NEUTRAL] A copy of the explanation of benefits it would have just been put out in the mail to you so you will get something showing the claim number and the reason for the denial, but if you want me to email that to you, I can do that.
[CUSTOMER][NEGATIVE] OK, that'll be fine, but um I mean I just need to know what all I need to do to to get this process rolling cause I mean I'm paying the insurance but yeah I'm getting denied, you know, it don't make sense.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So, we need an itemized medical bill from the provider that you saw to see what exactly was done and what the charges were, to see what the diagnosis was for the critical illness.
[CUSTOMER][NEUTRAL] All of that was in the form that
[CUSTOMER][NEUTRAL] The diagnosis and all that was in the form.
[AGENT][NEUTRAL] But they still
[CUSTOMER][NEUTRAL] It was filled out for the credit.
[AGENT][NEUTRAL] I understand, but we still need something from the provider showing the diagnosis code with like on an itemized receipt.
[CUSTOMER][NEUTRAL] Someone saved me a little popcorn. OK.
[AGENT][NEUTRAL] So you don't need to resubmit the claim form or anything like that. You could just upload that receipt.
[AGENT][NEUTRAL] And then they will continue to process out the rest of the claim.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so just, I just need to get with my provider, um, the doctors and tell them that they need to send y'all a um an itemized bill.
[AGENT][POSITIVE] Correct with procedure and diagnosis code on it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But I didn't have the cold on the critical illness.
[AGENT][NEUTRAL] I don't see that there were, yeah, I don't see that there were any codes on there.
[CUSTOMER][NEUTRAL] I'm just, I'm just asking.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Cause I mean, doesn't it ask for a code?
[CUSTOMER][NEUTRAL] On the uh critical illness form.
[CUSTOMER][NEUTRAL] like a projector.
[AGENT][NEUTRAL] I'm pulling it back up here.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] No, it doesn't ask for any sort of codes or anything like that on there.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me check on the accident claim and see what that one says.
[CUSTOMER][NEUTRAL] So, uh,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Because that's the only thing that you need for the critical is just that that's the only thing it's asking for.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And when I just have them to uh fax it or email or?
[AGENT][NEUTRAL] They can fax it to us. Do you need the fax number?
[CUSTOMER][NEUTRAL] Uh, I think I have a fax number already.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the accident plan doesn't provide any benefit for it looks like what was done.
[CUSTOMER][NEUTRAL] But the bone marrow biopsy.
[AGENT][NEUTRAL] Yeah, so there was no coverage on the accident plan for anything of that nature.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that explanation of benefits will also be sent out to you also, um, all those are always sent in the mail. The claims were just processed so and they show a date of yesterday, so that's why you haven't gotten anything yet because they would have just been sent out.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Did you need me to check on anything else today, Ca[PII]?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] No, I think that'll be about it. I mean.
[CUSTOMER][NEGATIVE] I still don't understand that why, you know, uh, both were rejected because I mean.
[CUSTOMER][NEGATIVE] As far as like the biopsy or whatever, I mean, it asks you what procedures and that was one of the options. So why would they have that as an option then turn around and tell me that it's not covered.
[AGENT][NEUTRAL] Well, full disclosure that the claim form that was submitted, Ca[PII]n that was a wellness claim form, not an accident claim form.
[CUSTOMER][NEUTRAL] Me
[AGENT][NEUTRAL] Um, we have an actual specific accident claim form.
[AGENT][NEUTRAL] So on the wellness, you know, we have different policies that offer wellness benefits.
[AGENT][NEUTRAL] But that it's not, it's just not on the accident policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So, I was diagnosed with leukemia, right? So, where would that fall under?
[CUSTOMER][NEUTRAL] That's basically what I really needed to know. Would it be like a cancer, critical illness, wellness, traditional?
[AGENT][NEUTRAL] Yeah, I mean, if
[CUSTOMER][NEUTRAL] Cause I, you know, I was trying to get help to try to, that's why I did different claims. I didn't know which one cause I, I couldn't get, you know, a specific answer to which one I should do.
[AGENT][NEUTRAL] Right, OK.
[AGENT][NEUTRAL] So you have an accident, a critical illness, and then it looks like life with us.
[AGENT][NEUTRAL] OK. So let me pull up.
[AGENT][NEGATIVE] The actual policy for your critical illness and just see what it says it's covered. I don't show that you have a cancer policy with us.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] OK. So in the critical illness policy and the certificate,
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK, so it does list.
[AGENT][NEUTRAL] Cancer and it states.
[AGENT][NEUTRAL] Invasive cancer and it states that including leukemia, lymphoma, and all those things are listed.
[AGENT][NEUTRAL] So what are
[AGENT][NEUTRAL] And.
[AGENT][NEUTRAL] Have you ever signed in online and done any is that where you were doing your claims, Ca[PII]I'm sorry I didn't even see.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, let's go back.
[AGENT][NEGATIVE] I think what threw you off was just that it wasn't the right form.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, so what form was it that I needed to fill out?
[AGENT][NEUTRAL] So it's the critical illness benefit form and
[AGENT][NEUTRAL] It states on the very first page if you're filing for a first time diagnosis, um, depending upon the plan, you know, that we need something with a medical record stating the diagnosis.
[AGENT][NEUTRAL] Um, if you're gonna be filing for like hospitalization or any of that, what is needed with that, it kind of breaks it down as far as like what you're filing for and what is needed with that. Would you like me to send you this just so you have it for reference because the first page is helpful just so you can refer to it as far as what's needed.
[AGENT][NEUTRAL] The plan itself does have a benefit for invasive cancer of up to $10,000.
[AGENT][NEUTRAL] Um, they're gonna need something just showing the diagnosis, and so that's why on the accident one.
[AGENT][NEUTRAL] It was asking for an itemized receipt with like a diagnosis code. That's what they're needing from the provider, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Because this claim form itself has a whole page for your attending physician to fill out. And it states, you know, they ask them, you know, what the diagnosis is. They ask, you know, all these different questions that have to be filled out and then it has to be signed and dated by them. So I need to, I need to send you this so you have it.
[CUSTOMER][NEUTRAL] So, I mean, that was a critical illness for him, right?
[AGENT][NEUTRAL] Let me go back to the other claim cause I don't.
[AGENT][NEUTRAL] I saw the wellness claim on this one. Let me go back here.
[AGENT][NEUTRAL] Yeah, so, on both of the policies, the form that was submitted was the wellness claim form.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That doesn't have a lot of the information that we need. Let me email you this form cause the, the critical illness form, it's much more in depth and like I said, your physician has to fill out a portion.
[CUSTOMER][NEUTRAL] OK, so I've done that already.
[AGENT][NEUTRAL] You've done the critical illness form already and sent it in?
[CUSTOMER][NEUTRAL] Yes, yes, ma'am.
[CUSTOMER][NEUTRAL] That's what, that's what I was trying to tell you. I've done the critical illness for and had it sent in. Uh, the doctor sent one, her part in and I uh sent in the first part that, uh, I had to fill out.
[CUSTOMER][NEUTRAL] Pages like 2 and 4, I think.
[CUSTOMER][NEUTRAL] And um the doctor filled out pages 5 to 9.
[CUSTOMER][NEUTRAL] On the critical illness form when I faxed it in.
[AGENT][NEUTRAL] When did they send it?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Let me go back. It was uh it was last Thursday.
[CUSTOMER][NEUTRAL] And I mean I still have copies of uh cause she sent me copies back from when she um filled it out as well.
[CUSTOMER][NEUTRAL] So I can easily, you know, email it to you or whoever.
[AGENT][NEUTRAL] I don't see anything past the 16[PII]so you can definitely resubmit it if you have it through the service center online or fax it. We just unfortunately can't get it in the email.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, when I look under each one, it just shows the wellness claim form. That was part of my confusion. I don't, I didn't see that we ever got the critical illness claim form.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah, I, I know for a fact that, yeah, um.
[CUSTOMER][NEUTRAL] I filled out, we filled it out and um it was sent back. She faxed it back.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] OK. Yeah, I apologize and um we can just resubmit it at this point.
[AGENT][NEUTRAL] Um, since we don't have that, I mean, that could be part of the denial also because, I mean, there's, like I said, we don't have any physician's information, so that's why it's asking for additional info, you know.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well, I mean, yeah, I could um resubmit those forms, uh, fax them back or however you need them done.
[AGENT][NEUTRAL] It's up to you honestly, whatever is easiest you can do it through the service center online and then if you wanna check back with us or you can send it via fax, whatever is easiest.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'll try the service center this time, you know, cause I mean, like I said, the fax it.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] You should get a yeah, you should get a confirmation right away.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I'm sorry about that, yeah, just resubmit that information and then if you want to check back with us to make sure we got it.
[CUSTOMER][POSITIVE] OK, and then if there's anything else, um, after the fact that I need to send in, you know, just, you know, feel free to contact me and let me know so I can kinda get the ball rolling.
[AGENT][NEUTRAL] Yeah, no, absolutely. They, I mean, the notifications are generally sent out like I said in the mail, um, as far as your explanation of benefits.
[CUSTOMER][NEUTRAL] On this claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But if you log on to the online service center, you can sign up for notifications. Like most of the time it'll send you an email or a text when the claim's been processed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, well, yeah, um, I'll get with that and um send that to the service center and uh if I need to, I'll fax them again as well that way.
[CUSTOMER][POSITIVE] You know, I, I won't miss.
[AGENT][NEUTRAL] OK, did you need me to check on anything else today?
[CUSTOMER][NEUTRAL] Uh, no, ma'am. That'll be all.
[AGENT][POSITIVE] Thanks for calling APL. I hope you have a nice rest of your day.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Bye bye.