AccountId: 011433970860
ContactId: c0ed1047-8911-4f7f-8b4a-31b344be6727
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 674659 ms
Total Talk Time (AGENT): 244812 ms
Total Talk Time (CUSTOMER): 373037 ms
Interruptions: 6
Overall Sentiment: AGENT=1.3, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/17/c0ed1047-8911-4f7f-8b4a-31b344be6727_20250317T17:57_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, uh, my name is [PII]. I have a, I mean, a, a question about, uh, uh EOB that I, uh, sheet that I received on a cancer claim. Uh, do you need my claim number, my account number, policy number, or what do you need?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Um, well, 1st may I have your name and a good contact number in case we're disconnected, but I'll be more than happy to help you with your claim.
[CUSTOMER][NEUTRAL] OK. OK. All right, [PII], and it's [PII].
[AGENT][NEUTRAL] Thank you. And Ms. [PII], may I have your policy number?
[CUSTOMER][NEUTRAL] It's 00640053.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, and I have you here. I just need you to verify your date of birth and the mailing address on file.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you and then your email address.
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And would this be for um claim 3576385?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, this is 356-795-7.
[AGENT][NEUTRAL] OK, I got it. OK, and um what questions did you have about the claim?
[CUSTOMER][NEUTRAL] OK. Uh, it, uh, on the sheet that I got that, you know, that told what everything was, the, the very last item on there, uh, with, uh,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The description number 7, which says the maximum payable benefit for chemotherapy radiation treatment benefit has been met for this benefit period. Can you explain what, what that means for future claims or, I mean, it paid on that.
[CUSTOMER][NEUTRAL] You know, I paid on that chemotherapy for the visit of [PII], but I didn't know what that meant for, for payments after that for claims after that. Mhm. What, what is that?
[AGENT][NEUTRAL] For this one.
[CUSTOMER][NEUTRAL] Oh, description name.
[AGENT][NEUTRAL] OK, hold on one moment. I'm.
[AGENT][NEUTRAL] I'm looking up the um benefits now so I can take a look. Do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] OK. Sure. Sure, that's fine.
[AGENT][NEUTRAL] All right, thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Chemo or daily hospital benefit with 7500 annual chemo limit, OK.
[AGENT][NEUTRAL] Chemotherapy and radiation on the C422. She doesn't have that.
[AGENT][NEUTRAL] OK, so what does it mean?
[AGENT][NEUTRAL] I need a, I need a breakdown of what that means.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh, that's the only schedule page. Alright, so we're gonna have to get claims.
[AGENT][NEUTRAL] All right, sorry. I, I don't know and I don't wanna tell you wrong.
[AGENT][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So this is what I'm gonna do because I looked up your your um benefits and I don't see a breakdown for the chemotherapy uh benefits. I'm gonna get a claims examiner on the line to explain it to you in more detail since they examined the claim, so they'll know.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] Alright, before I do that, was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEGATIVE] No, um, I, what does it mean like when there's a claim and it just out for the, um, you know, uh, on my explanation, it says no files. I, I don't understand how you had a claim when we uploaded everything. I don't know what that means when it says no files.
[AGENT][NEUTRAL] Where, um, where do you, you see that on the same claim here?
[CUSTOMER][NEUTRAL] Let me
[CUSTOMER][NEUTRAL] No, no, no, this is another one.
[AGENT][NEUTRAL] Which, which one are you looking at?
[CUSTOMER][NEUTRAL] OK, it's uh
[CUSTOMER][NEUTRAL] Like uh 355-5195.
[AGENT][NEUTRAL] OK, let me see for that one. Hold on one moment.
[CUSTOMER][NEUTRAL] See how you could have a there could be a claim if there weren't any files. There's several of them that'll say no files and I don't know what that uh what's going on with that.
[AGENT][NEUTRAL] Now, this, this, so it looks like there's 3 that have this um denial reason, uh, so the one you gave me, oh, I'm sorry, it's only 2, this is the same claim number. So it's the one.
[CUSTOMER][NEUTRAL] Uh-huh. Right.
[CUSTOMER][NEUTRAL] Yeah, well, I see.
[CUSTOMER][NEUTRAL] OK, yeah, I, I see what, OK, go ahead.
[AGENT][NEUTRAL] So it's the one you gave me and then 354-884-1. So this is, um, so these were denied saying that the policy does not provide benefits for office visits. We received the files, office visits aren't covered by the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, but it was
[CUSTOMER][NEUTRAL] OK. And there's one more, [PII] and it says the same, well, there's several on that say that. Does that just what that means is that, that it didn't, the benefit wasn't.
[CUSTOMER][NEUTRAL] whatever the claim was for the benefit, the policy doesn't cover that.
[AGENT][NEUTRAL] Yes, on the, if you see that um DC 001 next to it, that that one means that the um policy does not provide office visit benefits.
[CUSTOMER][NEUTRAL] 3
[CUSTOMER][NEUTRAL] Wait a minute. What, what did you say? If I see what now? I'm sorry. I can't, I didn't write it down.
[AGENT][NEUTRAL] It's OK. So it's D like dog, C like cat, 0001, it'll that'll be in the it'll be in the remark column.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] That code there means that the policy doesn't provide office visit benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, OK. So, so it doesn't necessarily mean that there, you didn't get a file. It just means there's nothing that
[CUSTOMER][NEUTRAL] On that policy that that the that the coverage that policy covers on for that type claim, right? That's kind of what it. OK. OK. All right. I, I just never have really figured that out how, you know, with no files and then well we sent, you know, we didn't step in. I don't know why there's how you could have had a claim without no ile. But then, OK, but I understand what you're saying now. So somebody's coming to, to explain the other thing about the what that first question was.
[AGENT][POSITIVE] Correct. Yes, ma'am.
[AGENT][NEUTRAL] Yes, so the first one, hold on one second.
[CUSTOMER][NEUTRAL] You said, OK.
[CUSTOMER][NEUTRAL] I mean, about the chemotherapy not being that, that, you know, but there's no uh the period had been met for that chemotherapy, the maximum payable.
[AGENT][NEUTRAL] And it was the last.
[AGENT][NEUTRAL] Hold on, I'm trying to find that code. Hold on one second.
[CUSTOMER][NEUTRAL] I guess that's all we're waiting for now.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I can give it to the rep that I get.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that claim was the 356-795-7 or was it a different? Did I pull up the wrong claim?
[CUSTOMER][NEUTRAL] Wait a minute. 356-795-7. Uh-huh. It's on that.
[AGENT][NEUTRAL] OK, no this is right, OK.
[CUSTOMER][NEUTRAL] Well there on that sheet that I got the where you explain the benefits. It was the very last.
[CUSTOMER][NEUTRAL] I listed on there.
[AGENT][NEUTRAL] Does that have the date of service [PII] next to it?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Uh but for that particular item where it said the benefit period had been met. Is that what you're saying, that particular one? It said from [PII], which that was the date I had che, one of the dates I had chemo.
[AGENT][NEUTRAL] Yes, ma'am. Mhm.
[AGENT][NEUTRAL] Wait a minute now, that's been paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I know, I know, but what I, I, you know, when it said remarks, it had number 7 out there like, and, and that's why I was just trying to figure out what that meant because it paid for that, but it's, it said on the other page, the maximum payable for the chemo radiation therapy benefit.
[CUSTOMER][NEUTRAL] Has been met for this benefit period. Is that, I mean, this means that's all they're gonna pay, which, I mean, that's, I unders you know, that's fine if that's all they're gonna pay, but I just didn't know if it meant something for future claims that it's not gonna pay anything.
[AGENT][NEUTRAL] Hold on, hold on.
[AGENT][NEUTRAL] OK, hold on one second, 7.
[AGENT][NEUTRAL] And then let me go down to 7.
[CUSTOMER][NEUTRAL] Maybe it just means that's all that it's gonna pay on that.
[AGENT][NEUTRAL] Oh, that's just saying that, oh, yes, ma'am, that's just saying for, for the amount that was billed, um, and how we have to split up, you know, because it's per calendar year, from what was billed to us, that was the max that we could pay, the $1,774.21. Yes, just for that claim.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] For
[CUSTOMER][NEUTRAL] For that, for this claim.
[CUSTOMER][NEUTRAL] Just like for this, OK. I just didn't know if it meant it wasn't gonna pay anything on any more claims, but that, OK, that I didn't understand that because I've never y'all had never had that on one of mine before, so I just was questioning what that, what that meant for that then. So I guess that's all I need to know then.
[AGENT][NEUTRAL] You sure? OK.
[CUSTOMER][POSITIVE] Yes, ma'am. You answer my question. That was what I was trying to find out what that, what that description meant for, for, for that. So thank you for, for your help, OK? My husband worked for American Public. My husband is a salesman for American Public for about 25 years, so y'all are a good company. Hey, uh, he
[AGENT][POSITIVE] You're very welcome, Ms. [PII].
[AGENT][POSITIVE] Really? Well, I'm glad you're still with us.
[CUSTOMER][NEUTRAL] Well, I'm still, he died about 11 years ago, but now I have cancer, so I'm filing on the policy that we had when that, you know, he bought when we were still living. So, but he was American public. I've, I've known, been associated with that for a long time through my husband working there.
[AGENT][POSITIVE] Well, we appreciate you and if you have any questions or you need anything, don't hesitate to give us a call.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yes, ma'am, I will. Thank you for your help. All right, bye-bye.
[AGENT][POSITIVE] Thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] OK, all right, bye.