AccountId: 011433970860
ContactId: c922ac00-7b26-4c8e-a631-1d16d4b4282b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 974460 ms
Total Talk Time (AGENT): 715299 ms
Total Talk Time (CUSTOMER): 249436 ms
Interruptions: 5
Overall Sentiment: AGENT=0.1, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/c922ac00-7b26-4c8e-a631-1d16d4b4282b_20250226T15:23_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APA. You're speaking with [PII]. How may I help you today?
[CUSTOMER][NEUTRAL] Yes, my name is [PII]. I just look on check on the status of my claim.
[AGENT][NEUTRAL] OK, and what's your name, sir?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. May I have your phone number just in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] All right. Do you have your policy number?
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] 2
[CUSTOMER][NEUTRAL] 566-030
[AGENT][NEUTRAL] All right, let me look that up.
[AGENT][NEUTRAL] All right, thank you. Can you verify your date of birth for me and your mailing address?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Uh [PII].
[AGENT][NEUTRAL] OK, alright. What, what about your email address on file?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] All right. Thank you for the information. And your calling and check and claim status?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK, looks like something was processed on [PII] I mean [PII], and let me see what they're asking for. Give me one second, see what they saying.
[AGENT][NEUTRAL] OK, I see that they need the.
[AGENT][NEUTRAL] I my surgery bill for date of service [PII]. Uh, let me go ahead and see what else they say.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, I've been said that on February on [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That bill I went do my policy, I've been sent that to them. They've been have that yeah.
[AGENT][NEUTRAL] OK. OK. I, I'll get them to go back, they just go back and look at that if that you say, but they say, uh please um uh uh check create need past medical issues. They on, OK, please complete the. They sent you a in on [PII] and it would be mailed out prior.
[AGENT][NEUTRAL] [PII] they're sending you a form to complete in order for us to get your medical records because your policy has a 12 month preexisting period on it and before any benefits can be paid, they have to get the medical records so they sent you something to for you to send back to us for us to be able to get.
[CUSTOMER][NEUTRAL] I gave you to me.
[AGENT][NEUTRAL] You gave it to
[CUSTOMER][NEUTRAL] And she told me to take. I gave it to the people I do do my work and the woman got on it Monday. She was, she only works on Mondays and Fridays, so she already faxed it over to y'all. She did it Monday.
[AGENT][NEUTRAL] OK, now we haven't received any new claims since we process your claim on [PII]. We haven't received any new claims, so, uh, you might wanna check with whoever you think that might have supposed to been sent something over to us and let me put up your.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Cause that that that the doctor, right?
[CUSTOMER][NEUTRAL] That was doing I was doing my paperwork. The people was doing my stuff, so that's for medical.
[AGENT][NEUTRAL] Well, what they, what the medical records, they, they're gonna request medical records from your treating doctor and they need medical records from [PII].
[AGENT][NEUTRAL] [PII]. We go back 12 months. So that's what the person that's gonna ask the person that's handling your claim would ask for those medical records once we get the paperwork we need to be able to get the medical records from your treating doctor. We go back one year.
[CUSTOMER][NEUTRAL] Well, I don't, I didn't get diagnosed with it until [PII].
[AGENT][NEUTRAL] I understand, but we still have to rule out the preexisting since there's, you know, you're still within your 12 months. If there's no medical records, your doctor will put on our claim form, no medical record during the requested time period. We just have to do our procedure when you're still in your one year preexisting period on this policy. So that's why.
[CUSTOMER][NEUTRAL] OK, so I need to call them and make sure they fax it over to you.
[AGENT][NEUTRAL] Well, what, what, what I think what they need from you is whatever they sent out to you on the [PII], that authorization claim for most likely what it was for us to be able to request them ourselves. We request the medical records, uh, so that's why they sent you something and you need to complete it and send it back to our office.
[CUSTOMER][NEUTRAL] OK, let me print that out again so I need to fill it out and send it back to y'all.
[AGENT][NEUTRAL] Uh-huh, yeah, yeah, something that let me, let me see what they sent you, but I'm looking at your client. I'm looking at your claim for you to see what you sent in since you said you sent in the itemized surgery bill. So let me look at what the the first client came in has 16 pages.
[CUSTOMER][NEUTRAL] Yeah, go ahead.
[AGENT][NEGATIVE] And, and I do not see a bill with this.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's in there. It was in there because I paid $500 due the biopsy. That was back in January.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh-huh, but we need to itemize surgery uh-huh, but we need to, OK, so you're saying you sent the bill.
[CUSTOMER][NEUTRAL] And the whole bill was 2.
[CUSTOMER][NEUTRAL] I sent that y'all a bill, man. I was in there. You will see $500 back in January and then you're gonna see a $500 payment and then you're gonna see a payment plan I set up with them for $102.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, but see, but you, OK, what you're misunderstanding, that's a bill that you got. We need to itemize surgery bill with the CPT code on showing the type of surgery was performed and how much it costs. So what I'm, I'm looking to see what you sent in, but that's what they're asking for the itemized surgery bill, not just a statement where you say, uh you had surgery.
[CUSTOMER][NEUTRAL] Because the whole thing was $2000.
[AGENT][NEUTRAL] Uh, $115 or 20, I'm just making up a day. 115 2025, total amount is $350,000 and uh you pay $200 on it like that. That's just a statement. We need to itemize surgery bill with the CPT code on uh-huh. So that's what they're asking for the itemized surgery bill from the surgeon.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, let me call them so they can fax it over to y'all, and it was $2000. That's what the whole deal was.
[AGENT][NEUTRAL] OK, uh-huh, so you need to ask for, tell them you need to make sure you tell them you need to itemize surgery bill. OK.
[CUSTOMER][NEUTRAL] $2000.
[CUSTOMER][NEUTRAL] OK then let me go uh hold on let me get y'all fast number so they can fax it right over to y'all. Hold on.
[AGENT][NEUTRAL] Uh, OK.
[AGENT][NEUTRAL] OK, OK, that's fine.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Yeah, I'm holding on because I'm looking through your paperwork to make sure, uh.
[CUSTOMER][NEUTRAL] Now I do that one thing y'all did send me. I still got a copy of it. It had my name and policy number and effect date on it. So that's the one I fill out and send back to y'all.
[AGENT][NEUTRAL] Uh, what does it say? What?
[CUSTOMER][NEUTRAL] It has uh
[CUSTOMER][NEUTRAL] Check one, pharmacy.
[CUSTOMER][NEUTRAL] Uh, specialists.
[CUSTOMER][NEUTRAL] Hospital
[CUSTOMER][NEUTRAL] Do therapy and all that stuff. It's like the same thing, only this one sheet of paper. It's one side of the same thing. It's, it's 6 of them on each side, 3 on one side and 3 on the other side.
[AGENT][NEUTRAL] OK. Did you get a, now that came from us cause I, we would have sent a, we, we, we would have sent an explanation of benefit. Looks like medical records uh has been requested from Doctor [PII] by uh uh no um [PII]
[CUSTOMER][NEUTRAL] OK, yeah, yeah.
[CUSTOMER][NEUTRAL] He
[CUSTOMER][NEUTRAL] Yeah, they the one that got mines over there right now that's the one that she gonna fax off to y'all. I gave them over to y'all, yeah.
[AGENT][NEUTRAL] OK, well
[AGENT][NEUTRAL] OK, well, you can call them and we, we, we, we request the medical record between [PII]. If they don't have any medical records, just tell them to send us a note saying no medical record during the requested time period. But this looked like this was sent to the doctor's office on, uh, when did they do this on [PII], they mailed off that letter to the doctor's office and I'm trying to see what else we got out here.
[AGENT][NEUTRAL] Uh, cause I don't, let me see who did that. But I would check with, but you definitely need to itemize surgery bill and
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So you, you can call the surgeon and have them to fax that over. Did I give you the fax number?
[CUSTOMER][NEUTRAL] Give it to me now.
[AGENT][NEUTRAL] 877.
[CUSTOMER][NEUTRAL] Hold on 877, go ahead.
[AGENT][NEUTRAL] 365.
[CUSTOMER][NEUTRAL] 365, go ahead.
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] 9
[AGENT][NEUTRAL] 423.
[CUSTOMER][NEUTRAL] 42.
[AGENT][NEUTRAL] 3.
[CUSTOMER][NEUTRAL] 942-3. OK, now back on [PII], a guy called in he sent the bill to y'all.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEGATIVE] For my first time I went there and it was just a, it was a bill for $279 what I owed.
[AGENT][NEUTRAL] Uh-huh, but see, but that's, see, but we can't use just a bill or statement. We have to have the itemized bills. So let me tell you what, what type of bill came in because this is what was here that came in and I'm, I'm gonna tell you what it was. It's, it's from the, uh, it's from Arkansas urologist.
[CUSTOMER][NEUTRAL] Did y'all get that?
[CUSTOMER][NEUTRAL] That's it, yes, ma'am.
[AGENT][NEUTRAL] And uh-huh, uh-huh, and on that bill, he got a lab, which you know layup is not covered on your policy. So layup is not covered and that's what it is, lab and then uh we need the itemized surgery bill for date of service uh [PII]. That's what we're asking for the itemized surgery bill.
[CUSTOMER][NEUTRAL] OK, let me call and get them for them right now so I can fax it over to you. And then y'all give me a call once y'all receive it. Can y'all do that?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh well, we won't call. No, we don't call. Your claim will fall in line because once the claim comes in our office, it falls in line and we have 7 to 15 working days to process a claim. We send everything by explanation of benefits when we process a claim. We never call and go over a claim over the phone because we can't process a claim over the phone with the insured, so it just falls in line and it'll be processed.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] But that's what we're needing the out my surgery bill and we requested medical records from that doctor I jus[PII] told you his name that was sent out on the [PII], and you can call your doctors and see did they get that request. And if they don't have any medical records during that time period, they just send us something back saying no medical records during the time period of [PII] to [PII] uh we go back one year one.
[CUSTOMER][NEUTRAL] [PII] hold on let me get this down 1.
[CUSTOMER][NEUTRAL] [PII] and give me the date of the [PII].
[AGENT][NEUTRAL] Of [PII] to.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Of [PII]. Uh-huh. We go back one year. Uh-huh. All right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I would have to call my, uh, uh, now I got those ones. I got those ones, the doctor in [PII], those medical records. I can fax those out to you all the day and you will not see that on there.
[AGENT][NEUTRAL] OK, now, you, we, we only want medical records from the last year. Nothing present. So anything present we don't need. We need
[CUSTOMER][NEUTRAL] You will see all you see.
[CUSTOMER][NEUTRAL] This is from last year. All my medical work in [PII] that I have right now for my doctor. Yes.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Well, that, well, that ain't the doctor she asking from. She asking for that doctor that starts with an [PII] How do you pronounce that?
[CUSTOMER][NEUTRAL] Doctor Who.
[AGENT][NEUTRAL] Uh-huh. That's who she getting medical records from. So we don't, she didn't ask for from nobody else.
[CUSTOMER][NEUTRAL] OK, then, well,
[CUSTOMER][NEUTRAL] Let me get that from them. Put on my phone, see if I can't find it. I got on my phone when I do that stuff and print it out and then send it over to you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, that's fine, but uh.
[AGENT][NEUTRAL] Anything else I can help you with today?
[CUSTOMER][NEUTRAL] So, it will take you 20 days to do this stuff right.
[AGENT][NEUTRAL] We, we have, when once the client come in our office, we have 7 to 15 working days to process a claim.
[AGENT][NEUTRAL] So if your client came in our office on today in the days of [PII], we have from the [PII] to whatever 15 up to 15 working days to review and process a claim. We'll process it if we need additional information, you will get the explanation of benefit saying why something couldn't be paid or why something was paid and that that's how it works, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, no, cause so basically.
[CUSTOMER][NEGATIVE] I might not get nothing paid for. I might just be stuck with everything and then I'm just paying y'all for nothing.
[AGENT][NEUTRAL] Well, I can't say that. All I can tell you is once we get the claim, if your policy covers whatever, whatever you send in, we will process it accordingly to the policy procedure and if that's a payable benefit on your policy.
[CUSTOMER][NEUTRAL] For example for them.
[CUSTOMER][NEUTRAL] OK, and if it's not, then it's just for me to pay, right?
[AGENT][NEUTRAL] Oh yeah, well, anything that your policy don't cover on anything you send in, it would be the patient responsibility. Yes, sir.
[CUSTOMER][NEUTRAL] So what best do y'all cover for me?
[AGENT][NEUTRAL] OK, let me go over your policy. Let me, OK.
[CUSTOMER][NEUTRAL] Cause they already told me, let, let me say when they told me I have my radiation treatment, it's $4000.
[CUSTOMER][POSITIVE] They have my radiation treat.
[AGENT][NEUTRAL] Who told you that?
[CUSTOMER][NEUTRAL] Because I had to do it for 9 weeks.
[CUSTOMER][NEUTRAL] The radiation doctors told me that when I go when I go.
[AGENT][NEUTRAL] Oh, I thought you're talking, I thought you're talking about, we told you that. I was just gonna say, uh, OK.
[CUSTOMER][NEUTRAL] No, no, my radiation doctor told me that's gonna be $4000 for 9 weeks of radiation treatment.
[CUSTOMER][NEUTRAL] So will y'all cover that or not? I need to know.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] there's no guarantee to pay over the phone. We do, once you send your claim in our office, it will be reviewed for payment. We do not process and guarantee anything over the phone. That's why we receive claims, we review them and process. Now you do have radiation benefits on your policy, and if you have radiation and it's you, like I said, the first thing they're doing is ruling out pre-existing medical condition. So if your claim is payable.
[AGENT][POSITIVE] For radiation, you have a benefit.
[AGENT][NEUTRAL] Every 12 month period I benefit up to $20,000 for chemo, chemotherapy, or radiation medical treatment on your policy. Let me give you an example. Say you went and had radiation today and the radiation amount, let me give you, I'm just giving you an example. Say the radiation amount that you had today, you, you pay the provider charged you $8000 for that one radiation treatment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Once you send your claim in here with your, let me see what state you're in.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] 00, I can send, once they, you send it in or they sending in your itemized radiation bill showing the type of radiation you had and say the bill was $8000 we will pay.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The $8000 and say the next time you had the bill, uh, it was $12,000 for that. Once we pay that $12,000 plus that $8000 that's $20,000 for that 12 month period. The next time we would be able to pay any radiation would be the next year, which would be uh [PII].
[AGENT][NEUTRAL] [PII] if you're still getting radiation. So any radiation after that, say you had some in April. Once you max out that $20,000 for that 12 month period, it won't start over again to the next 12 month period. So that's how it works. It's a 12 month period, a maximum amount of $120,000 per 12 month period.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, and the other one that I saw, what was that, uh, I said they said something like a 5000 $7000.
[AGENT][NEUTRAL] That's what we're checking, that's what we do. We check in pre-expo cause for just for being diagnosed with cancer, if it's internal cancer, you have a lump sum benefit that would pay a benefit of $5000.01 time per lifetime on this policy for just being diagnosed with internal cancer.
[CUSTOMER][NEUTRAL] OK, so that's [PII]. Let me call them right now and get me off so that they can faxed over to y'all. Thank you, ma'am.
[AGENT][NEUTRAL] All right. Anything else I can help you with today, Mr. [PII]?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Uh, you have well I appreciate you, ma'am.
[AGENT][POSITIVE] You're welcome. You have a great day and thank you for calling American Public Life. Bye-bye.
[CUSTOMER][NEUTRAL] Bye.