AccountId: 011433970860
ContactId: da1ca1ac-ce9c-45c7-96f6-cbd589da7773
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 689799 ms
Total Talk Time (AGENT): 286809 ms
Total Talk Time (CUSTOMER): 328077 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/da1ca1ac-ce9c-45c7-96f6-cbd589da7773_20250416T16:39_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], this is [PII] on the care team. I have a member on the line um for her cancer policy and I'm confused on how a claim would process. She's asking about how it processed, so gonna see if you could help me.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure. Do you have the policy number?
[CUSTOMER][NEUTRAL] It's 2,010,610.
[AGENT][NEUTRAL] OK, and who's the person on the phone?
[CUSTOMER][NEUTRAL] That's [PII] and I've verified her.
[AGENT][NEUTRAL] OK, and is this claim under who the claim under?
[CUSTOMER][NEGATIVE] Uh, well, the claim's not processed. She had skin cancer and had the most surgery, MOHS.
[CUSTOMER][NEUTRAL] Um, but so I'm reading in the policy certificate and this is I'm confused because.
[CUSTOMER][NEUTRAL] When I look up skin cancer.
[CUSTOMER][NEUTRAL] It has under the benefits.
[CUSTOMER][NEUTRAL] That it's covered.
[CUSTOMER][NEUTRAL] But then
[CUSTOMER][NEUTRAL] It it then it has that it's not covered under outpatient hospital or ambulatory surgical center benefit.
[CUSTOMER][NEUTRAL] So I'm not sure I'm not understanding how if if this is covered or not.
[AGENT][NEUTRAL] Sure. Well, I can definitely help her, but I'll just let you know that it is covered under the surgical benefit. So that's why it's not covered under the other benefits because it's not considered internal cancer, but for surgeries for skin cancer, yes, the surgical benefits are payable. But I can explain that to her.
[CUSTOMER][NEUTRAL] OK, sorry. OK, so will you explain it to me then? So it's, so it just won't pay under the hospital outpatient hospital or ambulatory surgical center benefit?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] But it will pay under.
[AGENT][NEUTRAL] So, because most of the benefits under this policy are gonna be payable for the treatment of internal cancer. So all those benefits that you see under that schedule, the majority of them, if, if it was internal cancer, um, then yes, those would be covered, um, or we could review those benefits for that treatment. But since skin cancer is not considered internal cancer,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The only benefits that are payable is for the actual surgical, you know, for the biopsy and then the removal of the cancer. And those are all under the surgical benefits.
[CUSTOMER][NEUTRAL] OK, OK, all right, that helps me at least know for future reference, but if you don't mind, would you be able to explain that to her?
[AGENT][NEUTRAL] Sure. And do you have a callback number?
[CUSTOMER][POSITIVE] OK, thank you so much.
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] OK, thank you so much appreciate it.
[AGENT][POSITIVE] Thank you for holding, this is [PII].
[CUSTOMER][NEUTRAL] Hey, um, is this the claims department?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] I have a question about the cancer policy.
[AGENT][NEUTRAL] Uh, yes ma'am. Do you mind if I go ahead and verify your full name?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, Ms. [PII], and you said you had a question regarding your, your cancer policy?
[CUSTOMER][NEUTRAL] Yes, um, I was wanting to see if it the surgery portion of it covers um removal of skin cancer.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh yes, ma'am. I can certainly help you with that. Um, so yes, your cancer policy would cover um, the, the, the surgical removal um of the skin cancer and also for the biopsy as well for the positive diagnosis.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, whenever you file your claim, you would just submit, um, the pathology report of when your cancer was diagnosed along with the itemized bill from the um surgical procedures.
[CUSTOMER][NEUTRAL] OK, um, now the, uh, I'm writing this down.
[CUSTOMER][NEUTRAL] The surgery was specifically the no surgery, MOHS, and it was done in the dermatologist's office. They do their most surgeries there. Does it matter that it was not in a hospital or how does that?
[CUSTOMER][NEUTRAL] Classify.
[AGENT][NEUTRAL] Oh, no, ma'am. Uh, that doesn't matter. Um, you would just still receive an itemized bill with the, the surgical codes on it, um, from that dermatologist's office.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and would that fall under, um, I'm looking at my list here, um, would that fall under the surgical schedule benefit or the outpatient slash it says outpatient hospital or ambulatory surgical center.
[AGENT][NEUTRAL] Right. So the outpatient hospital or ambulatory surgical center benefit, that's, that's the facility benefit for having it in an outpatient facility. But since this is skin cancer and not internal cancer, the benefit will be paid under that surgical benefit. And it will be calculated by the unit dollar amount which will be calculated once we receive the itemized bill with the surgical codes.
[CUSTOMER][NEUTRAL] OK, um, what does that mean? calculated per dollar?
[AGENT][NEUTRAL] Yeah, so the CPT codes that your physician will have on the itemized bills, there are those have a certain unit dollar amount and so under your policy it will pay $30 per surgical unit. And so once we receive those itemized bills, that's how we will calculate what the benefit amount is and the maximum per operation under your policy is $3200.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it does the max and so what we'll know the benefit amount once we have those codes from the itemized bill.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So each each procedure code has a certain number of surgical units attached to it.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Is that how that works?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and you won't know until you get that for like if it's the most procedure, you don't know what those surgical units normally are.
[AGENT][NEUTRAL] Right. Well, your um physician, whenever they bill your insurance, they choose the codes. So it'll be the codes that are on the itemized bill that, that, that your provider um has. Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so you said that $30 for surgical unit for the for the code and then you said something about um pathology also just for being diagnosed. What is that? I don't see that on my list.
[AGENT][NEUTRAL] It's the pathology report. So when they first did the biopsy to verify whether or not the lesion was cancerous or not, um, that's the document that you would provide so that we can confirm that it was a positive diagnosis of cancer.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so is there a payment just for that being positive or is the only thing it will fall under is that surgical?
[AGENT][NEUTRAL] Um, it will just fall under the surgical benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, and my last question is the 100 diagnostic testing writer.
[CUSTOMER][NEUTRAL] Um, like a wellness benefit, I guess.
[CUSTOMER][NEUTRAL] You follow me?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I have never submitted that and I've had this policy for quite a few years. How far back can you file that?
[CUSTOMER][NEUTRAL] You could get that.
[AGENT][NEUTRAL] Uh, sure, well, you can file it as far back as you had, um, eligibility, and it looks like the the effective date was [PII], so you'd be able to file each year after your effective date.
[CUSTOMER][NEUTRAL] OK, so, um, I also have like a hospital indemnity plan with um.
[CUSTOMER][NEUTRAL] With APL, but, um, the lady I talked to, she wasn't real sure but she was thinking that it was only about the 12 months. Um, do you only do the cancer?
[AGENT][NEUTRAL] Oh, I'm sorry, you said you had a question regarding your hospital identity policy?
[CUSTOMER][NEUTRAL] Yes, do you only handle the cancers or can you answer questions about the hospital indemnity also?
[AGENT][NEUTRAL] I can help you regarding hospital indemnity.
[CUSTOMER][NEUTRAL] OK, so I asked her the same question. I didn't realize that um APL had both my hospital and my cancer, so I didn't ask that lady about the cancer, um, but hospital indemnity, she said from what she was reading I could only file claims back for 1 year for 12 months, um, but now you're saying the wellness benefit can go back until the start date of my policy. Was she incorrect on the hospital or is that only 12 months?
[AGENT][NEUTRAL] Um, I'm not sure there may have been some confusion, but as long as you had active coverage with us, you can file as back far as you had eligibility, so it would be as far back as [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, yeah, she was actually reading something on the hospital and it said um file within 90 days um or as quickly as reasonably possible and that no claims after 12 months, so um.
[CUSTOMER][NEUTRAL] I guess I should just go ahead and submit them since you're reading something different or you're in claims, right? So you, I'll just go ahead and submit them um now what I'm wondering about on the hospital, um.
[CUSTOMER][NEUTRAL] Plan is like um emergency room benefits. I have one for this current year, but then there have been one or two in the past years, so I guess just go ahead and submit those.
[CUSTOMER][NEUTRAL] Is that what you're telling me?
[AGENT][NEUTRAL] Uh yes, you can, you can go ahead and submit them and we'll definitely review them. Um, there may be limitations on some benefits to be filed within 90 days or 12 months and that's normally because some of those like if it's like an accident they require.
[AGENT][NEUTRAL] Um, documentation or like hospital records and sometimes that can be hard to come by the, the longer you wait because you know hospitals are not gonna keep those documents for for so long. So that's why we just request that you know you try and file as soon as possible but you can definitely file and then we, we can review and if we need any additional information or if there are any um other exclusions under your policy, then we will be sure to reach out and let you know.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, alright, I appreciate it.
[AGENT][NEUTRAL] Uh, sure, Ms. [PII]. Was there anything else I could do to help you today?
[CUSTOMER][POSITIVE] That's all I needed. Thank you.
[AGENT][POSITIVE] Sure, thanks for calling AP I hope you have a good day.
[CUSTOMER][NEUTRAL] You too. Bye.
[AGENT][NEUTRAL] Bye bye.