AccountId: 011433970860
ContactId: b60e5a25-ceb8-4c0c-892f-8040141c9d75
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 946419 ms
Total Talk Time (AGENT): 422186 ms
Total Talk Time (CUSTOMER): 344319 ms
Interruptions: 0
Overall Sentiment: AGENT=0, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/14/b60e5a25-ceb8-4c0c-892f-8040141c9d75_20250514T16:18_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] with the care team at APL. I have a [PII] on the phone, and she is needing assistance with her claim denial, um, and she has a few questions that I am unable to answer. I was wondering if I could transfer her to you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, what's that policy number?
[CUSTOMER][NEUTRAL] Her policy number is
[CUSTOMER][NEUTRAL] 79318
[AGENT][NEUTRAL] OK and
[CUSTOMER][NEUTRAL] And it is for part 2?
[AGENT][NEUTRAL] OK, and what's the claim number?
[CUSTOMER][NEUTRAL] It is 359.
[CUSTOMER][NEUTRAL] 862 8.
[AGENT][NEUTRAL] OK, give me just one second to get that pulled up.
[CUSTOMER][NEUTRAL] And I know it was showing that it needed a primary um explanation of benefits, but she's needing more clarification on that and then she has some questions about the actual claim itself.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I have it pulled up?
[CUSTOMER][NEUTRAL] Are you ready for me to
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Get me some water in my cup.
[AGENT][NEUTRAL] Ms. [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hey, this is [PII] with the claims team. How are you today?
[CUSTOMER][POSITIVE] I'm good and you?
[AGENT][NEUTRAL] I'm doing well. um, so Ms. [PII] said that you had um some questions about your claim?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes ma'am, uh, I received from y'all an explanation of benefits from 121,220 to [PII], and that's when I did a chemo, my chemo and stuff, and it said on there that, uh, please provide copies of your explanation of benefits from your primary insurance carrier. I sent that in [PII], so y'all might have wouldn't got it until about probably about [PII] or [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I did just send you all a copy of that.
[AGENT][NEUTRAL] OK, and so you still haven't gotten any payment is that so that's why you're calling because we still haven't processed it?
[CUSTOMER][NEGATIVE] Well they they did process it but they didn't pay.
[CUSTOMER][NEUTRAL] Because they said they needed, you know, that explanation of benefits from my insurance which I sent to y'all [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] It's an explanation of benefits from [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Of [PII].
[CUSTOMER][NEUTRAL] Uh yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] My [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And they process the claim between those dates.
[AGENT][NEUTRAL] Gotcha. OK.
[AGENT][NEUTRAL] All right, um, let's see.
[CUSTOMER][NEUTRAL] Girl, I've been sending in a bunch of paperwork, so it might have got misplaced.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see, I'm trying to see if there was another claim out there that may have this date on it that I could go and like reference because the only thing I have received in March was for it was on [PII].
[AGENT][NEUTRAL] And it doesn't include the day. It does include.
[AGENT][NEUTRAL] Some dates from like October and November and December, but it's not that one specifically. I'll still pull it up. No harm in looking. Let's see.
[CUSTOMER][NEUTRAL] No, it's not because I look through my paperwork and it's not in the October.
[CUSTOMER][NEUTRAL] It's in the uh explanation because I, I make copies of each time I send.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And you mailed that in to us, is that correct?
[CUSTOMER][NEUTRAL] Now the
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, let me see here if I can find anything on this claim that has the same date.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] I'm looking my paperwork y'all sent me during the week and it doesn't that's the one they did it. The claim number is 33598628.
[CUSTOMER][NEUTRAL] They looked at it, but then they need that explanation to send.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] From my primary insurance.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] Let's see, I may have found something. I'm gonna look.
[AGENT][NEUTRAL] Over here and see if any of this matches up.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I do see where an explanation of benefits was submitted that has the 12/20 on it. I would just have to.
[AGENT][NEUTRAL] Like try and compare the numbers because the EOB doesn't include.
[AGENT][NEUTRAL] Um,
[AGENT][NEGATIVE] It doesn't include like the actual.
[AGENT][NEUTRAL] Information you know what I'm saying like it doesn't, it has like an where you were seeing and the date of service and the type of service, but it doesn't say like it doesn't split it up like the bill does so I would just have to um I think I found it though.
[CUSTOMER][NEUTRAL] I see.
[AGENT][NEUTRAL] I'm gonna have to double check myself. Let's see, yeah, those numbers add up. Let me see, they didn't put a note on that EOB either by chance, did they?
[CUSTOMER][NEUTRAL] Um, no, but I'm looking, uh, the 1220 EOB is [PII] and
[CUSTOMER][NEUTRAL] Just said, so I'm not seeing the EOV for the chemo chemo.
[AGENT][NEUTRAL] Yeah, so like I see radiology, which lines up with like your CT scan that you had that day.
[CUSTOMER][NEUTRAL] You know what I'm saying?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] And then I'll see.
[AGENT][NEUTRAL] For the hospital facility charge, which is the total charge for everything. So I'm seeing that. So it's really just trying to figure out, OK, did they put on this EOB?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Your like your drugs that you received because that's the only thing like some of the numbers I'm able to match up and I'm like, OK, yeah, I see that and I see that, but I'm not for whatever reason.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] That's not I haven't found that one. Would you be OK with me like sifting through what we've received to see if maybe it just got overlooked and then giving you a call back to let you know if we have it or not?
[CUSTOMER][NEUTRAL] Um, I'm looking at all of the EODs that I had, uh, faxed to you or mailed, yeah, mailed to you, but the only date that I see [PII], like I said, is the doctor.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And another doctor. That's it.
[CUSTOMER][NEUTRAL] I might have to send you an EOB from the chemotherapy.
[AGENT][NEUTRAL] Yeah, that's going to be because for this but for your policy, you know, it pays by um actual charges so it considers what your insurance, you know, approves or whatever and then it pays based off of that. So if we, if you have not submitted any EOB specific to your chemo, then we would need that to be able to consider the chemo.
[CUSTOMER][NEUTRAL] They might have
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Let me call MD [PII] and see your fax number is um [PII].
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, I'm gonna call them and see if they can fax you that the EOB on 122. Now I have another question. OK, what do they mean?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] By
[CUSTOMER][NEUTRAL] Charges submitted for routine lab, office visits, and or non-cancerid chemical substance are not payable unless a cancer.
[CUSTOMER][NEGATIVE] Cancer residual.
[CUSTOMER][NEUTRAL] Excuse me, chemical substance is administered on the same day. So is that considered chemo?
[CUSTOMER][NEUTRAL] Because these are the date that I received chemo.
[CUSTOMER][NEGATIVE] And they didn't pay nothing.
[AGENT][NEUTRAL] OK, so let's say charges submitted for routine lab, office visits and or non-cancerous at all chemical substances are not payable unless a chemo, yeah, so it would be a chemo substance is administered on the same day. So, let's see.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So we have [PII].
[CUSTOMER][NEUTRAL] I didn't get uh cancer on there. The dates that I got cancer, uh, I mean chemo, I'm sorry, is [PII], and [PII].
[AGENT][NEUTRAL] OK. So when you, when you receive that denial, um, so any, any day that you have an office visit or lab visits or anything like that, um, but it's not on the same day as your chemo, um, then it's not, it's saying that it's not payable on that.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] On that day because it wasn't the same day as your chemo. So that's really what that's saying. So any charges that you submit for like your lab work or your office visits, or any non-chemo drugs that you receive um on a day that you didn't also receive chemo. So let's say on [PII].
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Office visits and labs and stuff like that, any drugs that you received during that time, whether it be anti-nausea or, you know, some type of pain or what antihistamine, whatever it is that you receive, we'll look at those for payable benefits. But if it's on a day outside of that, like the one that I pulled up that has that remark code was 2:18. That was an office visit, but you didn't have chemo that day. So because you didn't have chemo, it's not payable under your benefits.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEGATIVE] They didn't. They're not OK. So every time I go to [PII], I do the lab work and probably scanned and then I see my oncologist the same day that I get, so you don't pay the doctor.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We do on the same day that you get chemo.
[CUSTOMER][NEUTRAL] Because I did on [PII].
[CUSTOMER][NEUTRAL] OK, but they said [PII].
[AGENT][NEUTRAL] OK, so for those 3 days, you have not gotten labs or office visits or drugs paid?
[CUSTOMER][NEUTRAL] They paid
[CUSTOMER][NEUTRAL] Yes, I did.
[AGENT][NEUTRAL] Oh OK.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Right, um,
[CUSTOMER][NEUTRAL] Because I those dates I did receive chemo like I said, but it says re re physician's referral and it says non-covered service so I'm just I'm thinking y'all don't pay the doctor pay me we're going to see the doctor and then get my chemo.
[AGENT][NEUTRAL] Not if it's not on the same day as chemo like this particular one that I'm looking at I don't know what claim number it is that you're looking at but this date of service is [PII]. If you did not receive chemo that day.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] See, I didn't even get nothing for [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, I got something for [PII].
[CUSTOMER][NEUTRAL] [PII] and [PII].
[CUSTOMER][NEGATIVE] That they didn't pay anything.
[AGENT][NEUTRAL] OK, alright, I will look into those and see if those benefits overlooked were overlooked.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] So you did find my explanation of benefits.
[CUSTOMER][NEUTRAL] For the other claim for my chemo on [PII] but I need to get you a UBO4 from MD [PII].
[CUSTOMER][NEUTRAL] Uh, for my chemo chemo on [PII], right?
[AGENT][NEUTRAL] No, we have the UB we don't have a detailed explanation of benefits. It, the explanation of benefits doesn't break down the charges for the medications that you received. It just has the facility and then like your radiology that you received, um, like the, I'm assuming that's like the CT scan or, you know, something along those lines.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, and then I think there was one other charge, but none of them are, are for.
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] The chemo itself.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, I'm gonna give them a call and I'll have them fax it to you.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, and I will, yes ma'am, and I will look into um into these labs and office visits and everything um for those dates that you did receive that you provided the [PII], the [PII], and the [PII] to see if we have um the information that we need for those benefits, but we just didn't pay, so I'll definitely look into that for you.
[CUSTOMER][NEUTRAL] Is that good?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, because they paid me, you know, like I said, uh, [PII] and uh [PII], they paid me for my chemotherapy, but I don't know if this refers to the doctors or what.
[AGENT][NEUTRAL] Got you. OK.
[AGENT][NEUTRAL] I will definitely look into that.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] I'm gonna
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] OK. You're very welcome. Have a great day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] All right. Bye-bye.