AccountId: 011433970860
ContactId: d45b2d7a-569b-49eb-bb10-4546e41830c1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 366709 ms
Total Talk Time (AGENT): 155938 ms
Total Talk Time (CUSTOMER): 160492 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=2.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/18/d45b2d7a-569b-49eb-bb10-4546e41830c1_20250218T20:35_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Well hey [PII], it's [PII]. How are you doing?
[AGENT][POSITIVE] I'm good [PII] how are you?
[CUSTOMER][POSITIVE] I'm doing well, thank you for asking. I have an insured on the line um calling regarding your claim.
[CUSTOMER][NEUTRAL] Status, it's policy number 252-8619.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right [PII].
[CUSTOMER][NEUTRAL] Yeah, I told her that we just received that on the [PII], and she's wanting to know she said it is for a biopsy and she's wanting to know what the policy pays toward a biopsy.
[CUSTOMER][NEUTRAL] And if we need any other information.
[CUSTOMER][NEGATIVE] She's just going through a hard time right now, I think, and.
[AGENT][NEUTRAL] OK, sure, you can send her over.
[CUSTOMER][NEUTRAL] And I wasn't, I wasn't exactly sure on the surgical benefits if that's for biopsies or what, but I appreciate you helping her and I verified all of her information.
[AGENT][POSITIVE] No problem.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Let me get her on the line. Thank you, [PII]. Good to talk to you.
[AGENT][NEUTRAL] Same.
[CUSTOMER][POSITIVE] Thank you. One moment.
[AGENT][NEUTRAL] All right.
[CUSTOMER][POSITIVE] This [PII], thank you for your patience. I have [PII] on the line and she's going to take a look at that for you and assist you further.
[CUSTOMER][POSITIVE] Great thank you. Thank you bye bye.
[AGENT][NEUTRAL] Hi [PII], my name is [PII] in the claims department. How are you today?
[CUSTOMER][POSITIVE] I'm fine thank you.
[AGENT][NEUTRAL] I understand you have some questions about your claim.
[CUSTOMER][NEUTRAL] Yes, I was wondering, do y'all need any additional documentation for that claim?
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] Alright, so I showed the most recent claim received on [PII]. Is that the claim in question?
[CUSTOMER][NEUTRAL] Yes ma'am, I sent additional documents to go with another claim that was filed on the [PII].
[AGENT][NEUTRAL] OK, yeah, so, um, that claim is in line to be processed. It hasn't been reviewed just yet. It's, uh, typically 7 to 10 business days from the date of receipt for the claim information to be reviewed and a claim decision made.
[CUSTOMER][NEUTRAL] OK, so it doesn't need any additional documents. They are just deciding if you're gonna process it or not.
[AGENT][NEUTRAL] Well, no, it hasn't been reviewed yet. We show that we've received claim information but it's in line to be processed so it hasn't, there hasn't been any eyes on the information received just yet.
[CUSTOMER][NEUTRAL] OK, so you don't know any if it you'll need anything additional yet because nobody's reviewed it.
[AGENT][NEUTRAL] That's correct. It takes 7 to 10 business days from the date of receipt.
[CUSTOMER][NEUTRAL] OK, well, I was hoping that you'll at least tell me if you need those things because I was told that I had a surgical benefit for biopsies and according to my deal I had it so I just want to check to make sure that was correct that y'all do have something in line for, for biopsies.
[AGENT][NEUTRAL] Yeah. And this is a verification of coverage. It doesn't guarantee the payment of a claim. Uh, if the biopsy resulted in a positive diagnosis of cancer, then that will be considered under the surgery benefit.
[CUSTOMER][NEUTRAL] OK, so a negative one would not be considered surgical?
[AGENT][NEUTRAL] That is correct. If it's negative, then it'll fall under the preventative benefit where there's diagnostic testing for cancer. So you'll, um, if it's a negative diagnosis of cancer, that would be considered under the preventative benefit.
[CUSTOMER][NEUTRAL] OK, I think I've already used my preventative benefit this year, is that correct?
[AGENT][NEUTRAL] I can take a look at that.
[CUSTOMER][NEUTRAL] Because I know I also have a, a benefit for also it says I have a follow up benefit as well but I don't one of those got denied.
[AGENT][NEUTRAL] Was the biopsy performed this year, [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yeah, so I don't, I don't show where we've, uh, paid the benefit for [PII].
[CUSTOMER][NEUTRAL] OK, so it would just be a $50.
[CUSTOMER][NEUTRAL] Exam benefit
[AGENT][NEUTRAL] That is correct. If that biopsy was negative for cancer.
[CUSTOMER][NEUTRAL] So yeah, it's all it would, would pay. It wouldn't pay underneath um a follow up or anything.
[AGENT][NEUTRAL] That will be determined um based on the information received. If the follow-up was um a follow-up to a preventative service that was performed prior, then it's possible, but it's hard to tell without um reviewing the claim information.
[CUSTOMER][MIXED] OK. I just want to make sure that I don't know how that works, but I had one in last year and they made me do a follow-up and they made me do a colonoscopy and they made me do um biopsies. They made me do all this testing and it cost a lot of money and I was glad it was negative, but still, it, you know, required a bunch of money and testing for co-pays and all that stuff. I was hoping to get some kind of reimbursement somewhere.
[AGENT][NEUTRAL] Understood. Yeah. So, we go through the information that you submit and uh basically side by side with the benefits available on your policy and wherever we identify a pay, a payable benefit, then we go ahead and process that accordingly. Uh, so no worries. If you submitted that information, um, we'll be able to look through that and determine where that particular biopsy will fall.
[CUSTOMER][NEUTRAL] OK, and if they gave me like um vaccines or anything like that, do I have any coverage for those or cost or no?
[AGENT][NEUTRAL] No, vaccines are not covered.
[CUSTOMER][POSITIVE] Alright, thank you.
[AGENT][POSITIVE] No problem. Is there anything else I can help you with today, [PII]?
[CUSTOMER][POSITIVE] That's all. I appreciate it. Bye.
[AGENT][POSITIVE] No problem, thanks for calling ATO have a great day.