AccountId: 011433970860
ContactId: d54853a2-219b-4a45-b1c7-db209cea8f18
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1154680 ms
Total Talk Time (AGENT): 340376 ms
Total Talk Time (CUSTOMER): 548318 ms
Interruptions: 2
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/28/d54853a2-219b-4a45-b1c7-db209cea8f18_20250328T19:19_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, hi [PII]. This is [PII]. Uh, I need the guidance. Uh, I would like to file an appeal.
[AGENT][NEUTRAL] OK, on just like how to file an appeal?
[CUSTOMER][NEUTRAL] Yeah, like internal, uh, appeal is that what you call it? I don't know, it's my first time, so yeah, that's why I need the guidance like how to start an internal appeal.
[AGENT][NEUTRAL] OK, yeah, and it's your policy, correct?
[CUSTOMER][POSITIVE] Correct, yes, yes.
[AGENT][NEUTRAL] Oh, OK. All right. Do you have your policy number by chance? I can pull that up.
[CUSTOMER][NEUTRAL] Uh, let me, yeah, I'm not sure if this is the correct one. So, uh, I know I got two policies before, before it was denied. First one is cancer policy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, the number I think is 249-1733.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then the other one is critical illness. Number is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] All right, thank you, [PII]. And then, uh, is this number you're calling from a good callback number if the call drops, is it [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Yes, that's correct, that's my cell phone number.
[AGENT][NEUTRAL] Thank you. Alright, and then for verification, I do need to get please your date of birth and address.
[CUSTOMER][NEUTRAL] Sure. Date of birth [PII]. And my home address is [PII].
[AGENT][POSITIVE] All right, thank you so much, so.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. So the appeal, are you filing it on the um critical or the cancer?
[CUSTOMER][NEUTRAL] Both because I believe the critical was denied, yeah, because the cancer was initially denied, so.
[AGENT][NEUTRAL] On both.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Yeah, mhm.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] Let's see, alright, so, um, appeals need to be, um, have to be done in writing, and they have to be sent to us. The appeal mailing address you're going to address the envelope to APL attention appeal department.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh hold on attention appeal department.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] [PII]. OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that's in [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the zip code is gonna be [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You have 180 days from the decision date to file the appeal.
[CUSTOMER][NEUTRAL] 180 days.
[CUSTOMER][NEUTRAL] Uh, from, uh, what's it again, from the day.
[AGENT][NEUTRAL] Um, from the date of denial.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] What is 180 days? How many months is that?
[AGENT][NEUTRAL] 3
[CUSTOMER][NEUTRAL] Uh, OK.
[AGENT][NEUTRAL] About that, 369. No, it's 6, sorry, it's 6.
[CUSTOMER][NEUTRAL] 03?
[CUSTOMER][NEUTRAL] 6 months
[CUSTOMER][NEUTRAL] Oh my goodness, uh, I think, can you check when the cancer was denied?
[AGENT][NEUTRAL] Yeah, let me take a look, one sec.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so the original it looks like I'm showing the denial date was [PII].
[CUSTOMER][NEUTRAL] Uh, what's that? Is that the cancer or the critical illness?
[AGENT][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] That was for the cancer.
[CUSTOMER][NEUTRAL] Which one?
[CUSTOMER][NEUTRAL] For the cancer too.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh, sorry. So that's [PII].
[AGENT][NEUTRAL] Mhm and the claim number for that one was 3566092.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 092. OK. So again, let me repeat that. So you said uh the cancer was denied [PII]. Claim number is 3566092.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Mhm, correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, and for the critical illness.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] That one.
[AGENT][NEUTRAL] sure.
[AGENT][NEUTRAL] The critical illness is showing a date of [PII].
[CUSTOMER][NEUTRAL] OK, [PII]. OK, and for the claim number.
[AGENT][NEUTRAL] That one was 354-7071.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 354-7071. So it was denied [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh boy.
[CUSTOMER][NEGATIVE] Oh, that's just sad.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, it'll just need to be a letter in writing stating why you're appealing the decision on each claim. Once you mail that stuff in, the status of an appeal can take 30 days to render um any sort of decision.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Do I have to submit any documentation as aside from the letter?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] No documentation is required. Um, however, if you have any supporting documentation as to why you're appealing the decision, I would include that information along with the appeal.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Like, uh, the EOD is that, uh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, I mean it looks like the denial reason on here was showing preexisting condition maybe.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] So if you have any sort of supporting documentation to prove otherwise that the claim can be processed and paid, I would submit submit that, but it's not required.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, and is, uh, I've been hearing before, like, uh, can the doctor can also submit or uh submit, uh, like the appeal? Is that possible?
[AGENT][NEUTRAL] Yes, the provider, yes, the provider can submit the appeal on your behalf as well.
[CUSTOMER][NEUTRAL] Is it true?
[CUSTOMER][NEUTRAL] Oh, OK. What is that? Do we just have to ask them to give us a paper, something like that?
[AGENT][NEUTRAL] You would just, yeah, they, they would just need to you know uh have something in writing stating why the um decision is being appealed and then they could either mail that to us on your behalf or you could send it on their behalf.
[CUSTOMER][NEUTRAL] Is that how we do it?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. OK, OK, let me, uh, well.
[CUSTOMER][NEUTRAL] And this, um, I think statement, right? Is that MD statement or something?
[CUSTOMER][NEUTRAL] OK alright for that and
[CUSTOMER][NEUTRAL] OK, just making sure that it was denied February and uh January.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEGATIVE] This, uh, yeah, you know why it's a little bit confusing with this one. I get scared because the I actually enrolled with you guys via, you know, a broker.
[CUSTOMER][NEUTRAL] And uh the I'm not sure if you're familiar with the employee retention benefits, the ERB so I've been waiting for them, you know, for any updates so it looks like it's always delayed by the time they informed me it was already in February.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You know, March, uh, yeah, it was already in February and at that time they didn't even know why the critical illness or the cancer, you know, they didn't know the hold up. That's the term they used, you know, like, oh, we don't, you know, let me check, you know, uh, try to figure out what's the hold up, why you haven't been paid for the cancer. Yeah, so.
[CUSTOMER][NEUTRAL] That's why, you know, everything I decided just to call you directly because it looks like it's taking forever and now good thing, you know, I called because there is, I didn't know that there's a deadline. There is, you know, 180 days you said from the date that was denied.
[AGENT][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] You know, so.
[CUSTOMER][NEUTRAL] Yeah, so this one I'm gonna have to perhaps uh contact my doctor. Hopefully they can help me with this one. Because what happened was um they
[CUSTOMER][NEUTRAL] Uh, I, uh, I think the effective date was [PII], and then I got biopsy, you know, the biopsy was [PII], and that's why I was surprised, like it was denied, although I have the routine, you know, just the routine uh mammogram because it was a breast cancer, so it was a routine mammogram in March, and they said that's the reason why it was uh pre-existing. That's the time they found that there's something clusters like there.
[CUSTOMER][NEUTRAL] And then I said like, uh, well, they did not diagnose it. In fact, the biopsy, they didn't actually recommend it initially. I was the one who insisted because I just wanted, you know, to make sure. So when it came back, it's positive, but that was already right after, you know, the effective date. So that's why I'm appealing because I said, uh, there must be a misunderstanding there, you know, initially they didn't diagnose. It was never diagnosed before, you know, [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] So yeah, it's like at first it was really frustrating, yeah, because I have, you know, I was out of work and then you were expecting this one. That's why I actually got this, you know, hoping that one day if something happens to me, you know, that they have to take care of my bills, yeah, so yeah, this one. So, uh, you said like, uh, just send a letter and then the supporting documents and then send it to the address you mentioned.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And can I also request, um, can you uh send me, you know, the report of the person who reviewed?
[AGENT][NEUTRAL] You should have
[CUSTOMER][NEGATIVE] You know, the person who actually denied it.
[AGENT][NEUTRAL] You should have gotten a copy of the explanation of benefits for the denial. Did you get that?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Uh, is that, uh, it's just a one liner thing, is that the one? It's not a complete explanation. It's just one sheet and I don't know, it's just an explanation. I think that's just a notification that was denied. I haven't received any, you know, uh, explanation.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, if you can send it to me by mail or I don't know if it's better for uh for you to send me via email.
[AGENT][NEUTRAL] Um, yeah, we can send it to you in the US postal mail or in the um.
[AGENT][NEUTRAL] Via email, whatever is your preference.
[CUSTOMER][NEUTRAL] Yeah, sure, uh, can you send it to me, my email?
[CUSTOMER][POSITIVE] It's quicker that way and I can check it right away if I get it.
[AGENT][NEUTRAL] OK, yeah.
[CUSTOMER][NEUTRAL] Uh, let me know when you're ready. I'll give you my email address.
[AGENT][NEUTRAL] What's your email?
[CUSTOMER][NEUTRAL] OK, uh, let me double check this one.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Hold on one second. OK, so it's uh [PII].
[CUSTOMER][NEUTRAL] And then [PII]. So again, that's [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, I will email you the explanation of benefits on each of the claims that way you have that for your records as well.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Correct, yeah.
[AGENT][NEUTRAL] Was there anything else, [PII] that I could check on for you today?
[CUSTOMER][NEUTRAL] Uh, I think that's it for now, but, uh, did you send it already? Because I'm waiting. I just wanna make sure I get it before I hang up, otherwise.
[CUSTOMER][POSITIVE] I'll be calling you again in the future.
[AGENT][NEUTRAL] OK, yeah, give me just a second.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] [PII], thank you very much for your assistance and for your patience.
[AGENT][POSITIVE] Yeah, you're welcome.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] How many times we can do an internal appeal?
[AGENT][NEUTRAL] Uh, it would be once.
[CUSTOMER][NEUTRAL] Oh, after that, if it's still get denied, then we can do the external appeals, right?
[AGENT][NEUTRAL] Correct, because the decision was upheld. So they'll mail you a letter with the determination of the appeal. And so, um, yeah, if the appeal is upheld, meaning the decision is upheld, you um unfort you can't appeal it any further.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For the that's for the internal appeal.
[AGENT][NEUTRAL] Right, there's only one appeal that you can do, that's it.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, OK.
[CUSTOMER][NEUTRAL] OK, let me see.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Is this just one page or two pages? I've actually got one from you, [PII].
[AGENT][NEGATIVE] Yeah, it's just, it's just 2, it's just 2 pages.
[CUSTOMER][NEUTRAL] Uh, 2 pages.
[CUSTOMER][NEUTRAL] Um, 14.
[AGENT][NEGATIVE] So the first page is just gonna tell you the date of service, what was being claimed, and then the second page tells you the reason for the denial, um.
[CUSTOMER][NEUTRAL] 6:14.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] That's standard as far as what is sent out on any claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] OK, is this uh for.
[CUSTOMER][NEUTRAL] Uh, for both, for, for cancer and uh.
[CUSTOMER][NEUTRAL] The critical.
[AGENT][NEUTRAL] No, ma'am, that's just the one. I'm sending the 2nd 1 now.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, the 2nd one's on its way to you, [PII], OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And since I have multiple physicians, uh, I just need one, right? Like,
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Maybe the surgeon or the oncologist, whoever.
[CUSTOMER][NEUTRAL] Is there a specific position or whoever just, you know.
[AGENT][NEUTRAL] Yeah, there's there's no um like I said that's not even required so if you choose to do that on your own accord, um, yeah, it would just be whatever your preference is because um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You know, if it's a specific provider that you're having appeal it for you, then, you know, I would go to them directly.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK. All right. OK. Thank you very much, [PII]. I think that's it for now.
[AGENT][POSITIVE] All right, sounds good. You're welcome. I hope you have a nice rest of your day.
[CUSTOMER][POSITIVE] Thank you for your time.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yeah, well, because of you, yeah, I have hope now.
[AGENT][POSITIVE] Good deal. I'm glad to hear it.
[CUSTOMER][POSITIVE] Yeah. Thank you, [PII], bye. Have a good one, bye-bye.
[AGENT][POSITIVE] You're welcome. You too. Take care.