AccountId: 011433970860
ContactId: c153d732-c00b-4bba-9bcb-95ade8703033
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 805929 ms
Total Talk Time (AGENT): 305634 ms
Total Talk Time (CUSTOMER): 276343 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/29/c153d732-c00b-4bba-9bcb-95ade8703033_20250529T15:32_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Yes, hi. Um, I just called and spoke with someone else, um, but I have some further questions.
[CUSTOMER][NEUTRAL] Um, about, uh, what coverage I might have for a surgery.
[AGENT][NEUTRAL] OK, and your name is?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and Ms. [PII], do you have the policy numbers in regards to?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Let's see, I think I've been logged that way, um.
[CUSTOMER][NEUTRAL] 252-247-2
[AGENT][POSITIVE] OK, thank you, give me a moment.
[CUSTOMER][NEUTRAL] It's the latest.
[AGENT][NEUTRAL] OK, and Ms. [PII], uh, verify your date of birth, mailing address and email address for me, please.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And [PII].
[AGENT][NEUTRAL] OK, thank you. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK. And you say you're inquired about the policy covers surgery?
[CUSTOMER][NEUTRAL] Yeah, I'm uh due for uh.
[CUSTOMER][NEUTRAL] I've, I've had a mastectomy and reconstruction and now,
[CUSTOMER][NEUTRAL] I am going in for a revision, so it would be liposuction and fat transfer and.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, when I called earlier to ask what kind of payment that might be.
[CUSTOMER][NEUTRAL] She said it depended on the number of units, surgery units.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEGATIVE] I have no idea what that means. So I called the surgeon's office. They said they've never heard of such a thing. They didn't know what it meant. I called the hospital, I called the hospital. They said they've never heard of such a thing either, had no clue what the unit would be a surgery unit.
[CUSTOMER][NEUTRAL] Uh, but they, they did give me some codes. Is there a way I could get just some idea of what the payment would be based on the procedure codes?
[AGENT][NEUTRAL] Uh, give me one.
[CUSTOMER][NEUTRAL] Rather than surgery units.
[AGENT][NEUTRAL] Give me one moment I'm looking up your policy.
[AGENT][NEUTRAL] Well, uh, I'm sure there's a surgical benefit, but it's for
[AGENT][NEUTRAL] A mastectomy.
[AGENT][NEUTRAL] I don't see a separate uh benefit for um any kind of additional surgery or different surgery besides the mastectomy.
[AGENT][NEUTRAL] See
[CUSTOMER][NEUTRAL] Well, this would be uh a follow up to the mastectomy.
[AGENT][NEUTRAL] Oh wait, there's a surgical benefit. Um, but it just pays based on a procedure code. I think what she's talking about it's unit. I don't know, sir, what she gets unit from, but
[CUSTOMER][NEUTRAL] A revision to the mastectomy.
[CUSTOMER][NEUTRAL] Well, I've, I've got
[CUSTOMER][NEUTRAL] I don't know what the unit thing is.
[AGENT][NEUTRAL] Uh, what's the procedure called?
[CUSTOMER][NEUTRAL] But I've got 3 procedure codes. OK, there's 3 of them.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, 19,380.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 19319316.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And 15771.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Well, uh, I see what the person previously probably.
[AGENT][NEUTRAL] Try to explain, but the surgical benefit pays based on the procedure code and there's a unit or unit value in relation to that code, but
[AGENT][NEUTRAL] Uh, that's not something we normally say. We just, uh, verify if there's a surgical benefit. Give me one moment.
[AGENT][NEUTRAL] 95.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So this would be uh reconstructive surgery due to a cancer diagnosis?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, give me one moment.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] 62.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] I'm sorry, I'm just looking up each one that's why I'm taking a while.
[CUSTOMER][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] 7.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and this is not a guarantee of payment. This is just a verification of coverage, um, but for procedure code 19,380, the max payable could be 27 85 95, so $2,785.95.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] For the procedure code 19316.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, the max payable is up to 3,825.
[AGENT][NEUTRAL] And for the procedure code of 15771, the max payable is 6-1920.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see. But if there's two or more surgical procedures uh performed during the same incision, uh, it would just be considered one. So they would pay the highest of those procedures. So, for instance, if you were to get the 9380 and the 9316 done on the same day, and it was for that same incision, then they would just pay the highest of the two.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Or vice versa with the other code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right. So there's multiple incisions. OK. So that leads me to another question that I think the other person I talked to told me the wrong thing.
[CUSTOMER][NEUTRAL] I was, uh, I received the payment.
[CUSTOMER][NEUTRAL] From surgery on [PII].
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] I just now as I was going through this, I looked at my.
[CUSTOMER][NEUTRAL] Claim
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And there's a note on there that.
[CUSTOMER][NEUTRAL] They only paid the higher one.
[CUSTOMER][NEUTRAL] Based on
[CUSTOMER][NEUTRAL] One incision, but it was definitely more than one incision.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Cause they took stomach fat and skin graft.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And reconstructed my breast, so.
[CUSTOMER][NEUTRAL] There was a full mastectomy and then there was the full reconstruction.
[CUSTOMER][NEUTRAL] So is it possible I'm do additional payment on that?
[AGENT][NEUTRAL] Um, looking.
[AGENT][NEUTRAL] I'm looking at the different ones, give me one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Uh, it looks like they paid one for that data service of 129,960.
[AGENT][NEUTRAL] And it looks like they paid on another surgery for that same day.
[AGENT][NEUTRAL] And it looks like they paid $2710.35.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Like two different surgery but on the same day. So it looks like it paid.
[CUSTOMER][NEUTRAL] OK, right.
[AGENT][NEUTRAL] Those twice as well as the anesthesia.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Can I gather, I don't know if I could gather from that that.
[CUSTOMER][NEUTRAL] Again, this will be two different, it won't be two different surgeries, but it will be two different.
[CUSTOMER][NEUTRAL] Incisions for sure.
[CUSTOMER][NEUTRAL] If not more.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Well, no, you answered my question based on the procedure codes.
[AGENT][NEUTRAL] Uh yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, yeah, OK. All right, well, that.
[CUSTOMER][POSITIVE] That clarifies quite a bit.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, OK. That's what I needed to know.
[AGENT][NEUTRAL] OK. And do you have a copy of your policy? And we do have it available on our online service center.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I don't.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um, so, yeah, how can I get to that?
[AGENT][NEUTRAL] Uh, if you go to, oh, go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] Like I
[CUSTOMER][NEUTRAL] Well, that's OK. I was just saying I don't see it on my dashboard like if I log into the portal, I don't see it anywhere.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Are you on the the [PII] site?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh, should, well, I know that they changed the, or there was some, uh, changes that were made to the site.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Trying to see if I have a user guide or something so I can view what you may see, but it should have somewhere to where it shows your different policies that you have to where or your policy that you have to where you can click on that policy number and the policy should pull up in PDF form.
[CUSTOMER][POSITIVE] Oh, you're right there it is, yes.
[CUSTOMER][NEUTRAL] OK, got it. Got it. OK.
[AGENT][NEUTRAL] And it goes through as far as each benefit that's covered and then it has a separate part it's like um.
[CUSTOMER][POSITIVE] Yeah, that's good to know.
[AGENT][NEUTRAL] Benefit schedule or schedule of benefits and you'll see all the different amounts that are payable for covered procedures. And then deeper into the policy, it kind of breaks it down, um, like if you scroll down, like for the surgery.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, it'll break down of how the benefit is covered.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Gotcha. OK. Very good. That's what I was looking for.
[AGENT][POSITIVE] Yes, ma'am. That schedule page helps out a lot. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, yeah, OK, wonderful.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right. Well, I appreciate your help.
[AGENT][POSITIVE] Alright, you're welcome, Ms. [PII]. And is there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] Uh, no, I think that's it.
[AGENT][POSITIVE] OK, well, I thank you so much for calling APL and you have a great rest of your day.
[CUSTOMER][POSITIVE] Thanks you too.
[AGENT][NEUTRAL] Mm bye.
[CUSTOMER][NEUTRAL] Bye-bye.