AccountId: 011433970860
ContactId: cb656dbc-963b-4017-bcfd-5667bdde28b1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 796940 ms
Total Talk Time (AGENT): 241930 ms
Total Talk Time (CUSTOMER): 233176 ms
Interruptions: 4
Overall Sentiment: AGENT=0.4, CUSTOMER=-1.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/09/cb656dbc-963b-4017-bcfd-5667bdde28b1_20250609T15:44_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APO. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] over in customer care. How are you today?
[AGENT][POSITIVE] I'm doing good how are you?
[CUSTOMER][NEUTRAL] Hey, I'm good um I have an insured on the line that would like to speak to somebody in regards to a claim. Can you help with that?
[AGENT][NEUTRAL] Uh, policy number?
[CUSTOMER][NEUTRAL] 730492.
[CUSTOMER][NEUTRAL] For [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the claim number is 36095002.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, we went over the denials and I was telling him that, you know, we needed an itemized surgery bill. Um, I did pull up what he submitted. He's giving a little pushback because he doesn't understand why the um health insurance information on the claim isn't being accepted when that has procedure codes on it.
[CUSTOMER][NEUTRAL] And so he was just asking to speak to somebody else.
[AGENT][NEUTRAL] Alright, send him on over.
[CUSTOMER][NEUTRAL] OK, I'm just gonna let him know I'm gonna transfer him one second.
[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] [PII], did she give you any of the information I gave her?
[AGENT][NEUTRAL] Yes, so she gave me your policy number, the claim number and um.
[AGENT][NEUTRAL] She was telling you about some of the the codes that we were needing.
[CUSTOMER][NEUTRAL] OK, do you have 5 pages that I faxed to you?
[AGENT][NEUTRAL] Yes, sir. I do.
[CUSTOMER][NEUTRAL] The one from the neurological people, specialists in [PII].
[CUSTOMER][NEUTRAL] At the bottom of the page there are 3 different codes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] They don't meet any of your requirements because that's what I got.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] Mhm pay report.
[AGENT][NEUTRAL] OK, so for the charges on 416.
[AGENT][NEUTRAL] Uh, of course, the office visits are not covered.
[AGENT][NEUTRAL] Lab work is not covered under the policy.
[AGENT][NEUTRAL] And the
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] The other 1 51798 that is not a cover charge under the policy. Let me see what that is.
[AGENT][NEUTRAL] OK, the urine capacity measurement, that's not covered under the policy.
[AGENT][NEUTRAL] And so in order for us to.
[AGENT][NEUTRAL] Uh, she did request the pathology report diagnosing the cancer.
[AGENT][NEUTRAL] So that we can uh.
[CUSTOMER][NEUTRAL] I got that. That's part of the that's the next page.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The 99204, that's not the, the biopsy itself.
[AGENT][NEUTRAL] Uh, no, so that's an office visit.
[CUSTOMER][NEUTRAL] So if I get you the paperwork, how much are you gonna pay for the biopsy?
[AGENT][NEUTRAL] Uh, let's see, give me a second to pull up your benefits to see what your benefits are.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And so do you have page 2 of the pathology report?
[AGENT][NEUTRAL] Um, because it looks like you only send in page 1 or 2.
[CUSTOMER][NEUTRAL] That's only
[CUSTOMER][NEUTRAL] That's all they gave me was page one.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I got, that's what I got from the doctor.
[AGENT][NEUTRAL] OK, so probably page 2 probably has more information that we're needing.
[CUSTOMER][NEUTRAL] So how much are you gonna pay?
[AGENT][NEUTRAL] I'm pulling up your policy. Give me one second.
[AGENT][NEUTRAL] OK, so until we actually get the.
[AGENT][NEUTRAL] Uh, pathology report and we probably gonna need the surgical charges.
[CUSTOMER][NEGATIVE] You got the pathology report, ma'am, that shows you I got cancer.
[AGENT][NEUTRAL] Sir, as I stated, they only, you only send in page 1 of 2, so page 2 is probably gonna have more information.
[CUSTOMER][NEUTRAL] More information about what? What are you looking for?
[AGENT][NEUTRAL] We, we have to have that information diagnosed in the cancer. So I do, you do have page one.
[CUSTOMER][NEGATIVE] The page, page 1 says, iron dycinoma, grade 1, grade 2. I mean, that tells you, I've got cancer.
[CUSTOMER][NEUTRAL] That's what the doctor went over with me.
[CUSTOMER][NEGATIVE] What more can you get that's going to show I've got cancer?
[AGENT][NEUTRAL] Probably page 2, probably page 2 is gonna actually have more information.
[CUSTOMER][NEGATIVE] No, it will not have any more information than what page one is showing you as far as my cancer. I'm going to call the doctor and they're going to tell me that I've got cancer and they're going to say, well, that page right there says that.
[AGENT][NEUTRAL] OK, that's that's fine.
[AGENT][NEUTRAL] OK, then that's what that's what we're needing, sir.
[CUSTOMER][NEUTRAL] Because right underneath it, part of it does is benign.
[AGENT][NEUTRAL] OK. And so in order to pay for the biopsy, we would need the charges for the surgery for the biopsy. And your surgical benefit pays between $50 and $5000 maximum, but it depends on the surgery benefit. So we have to have the charges in order to determine the payable amount for your surgery.
[CUSTOMER][NEUTRAL] So are you gonna pay for the whole surgical cost?
[AGENT][NEUTRAL] So without having the charge amount we have no idea what we would pay.
[AGENT][NEUTRAL] I leave it on, it would be between those two amounts.
[CUSTOMER][NEUTRAL] You can tell me whether you're gonna pay the surgical cost.
[CUSTOMER][NEUTRAL] All right, so I'm fixing to go into having a surgery to take out the prostate gland. What is this policy gonna cover going forward?
[AGENT][NEUTRAL] The policy pays in between $50 up to $5000 of surgical benefit, but it depends.
[CUSTOMER][NEUTRAL] Is that
[AGENT][NEUTRAL] Without the charge amounts we have no idea how much we're gonna pay.
[CUSTOMER][NEGATIVE] So if they charge me $100 you didn't mean you're gonna pay me $100?
[AGENT][NEUTRAL] Sir, I don't, we, I don't know, we don't process claims over the phone. All we can do is tell you what your benefit amounts are and we don't know until we actually get the information into our office.
[CUSTOMER][NEUTRAL] OK, I've had this policy since [PII].
[CUSTOMER][NEUTRAL] I've paid $826 for 25 years.
[CUSTOMER][NEGATIVE] Here I've got cancer and I'm needing this thing.
[CUSTOMER][NEGATIVE] And I'm finding out now that what I paid for is nothing.
[AGENT][NEUTRAL] I didn't say that what you paid for was nothing at this time. I cannot tell you the amount that we're going to pay. All I can give you is what your benefit amounts are. It pays up to $5000 so once we get the charge amounts in, then we can determine how much of that $5000 benefit we will pay.
[AGENT][NEUTRAL] But I can't say before we get those charge amounts how much we're going to pay.
[CUSTOMER][NEGATIVE] Why can't you? Why can't they tell me we're gonna pay what they charged?
[CUSTOMER][NEUTRAL] So what you're saying, do you pay 50% of what they charge? I mean, you got to have, if I get you the bill, you're going to have come up with some conclusion of how much you're going to pay that charge. I know it's 500 to $5000 but somewhere, once you get the bill, how much of the bill are you going to pay? You ought to be able to tell me that.
[AGENT][NEUTRAL] Uh, let's see what it says. Give me one second.
[AGENT][NEUTRAL] OK, so we would need the procedure code when you have the surgical benefit and then the surgical unit value is assigned to the procedure.
[AGENT][NEUTRAL] Um, multiply by the dollar amount showing on the scheduled benefits and the schedule of benefits, as I stated, pays up to $5000. So until we have the billing which shows the procedure code, the type of surgery that you had, the type of biopsy that you had, then we'll be able to look that up in our system and determine the payable amount.
[CUSTOMER][NEGATIVE] Alright, you just, I'm just telling you that I'm gonna call the insurance commissioner on this policy. I just think this thing is a sham as far as what you guys.
[CUSTOMER][NEGATIVE] led me to believe in what we got 25 years later. I just feel like this is the disgrace.
[AGENT][NEUTRAL] Yeah, actually, yes, actually it's not, but once we get the information we can review for payable benefits.
[CUSTOMER][NEUTRAL] All right, so you need a path, you need a bill for the actual biopsy with the code.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] Alright, if I get that to you today.
[CUSTOMER][NEUTRAL] Then how quick are you going to process this?
[AGENT][NEUTRAL] Uh, once it comes back in, it's treated as new information, so it would be the, you know, 7 to 10 days. Um, do you know what time they may send it in? I can try to look for it and have somebody review it.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] I'm hoping to get it to you today. I'm fixing to call him to say I need a copy of the biopsy report with the codes and I'm, and, and that's what you need for the biopsy, so.
[AGENT][NEUTRAL] Mhm. Yes.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] All right, thank you.
[AGENT][POSITIVE] Alrighty.