AccountId: 011433970860
ContactId: dfcb141f-9288-4ce2-82bc-b1d961e7bc4f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 917940 ms
Total Talk Time (AGENT): 438042 ms
Total Talk Time (CUSTOMER): 321172 ms
Interruptions: 8
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/07/dfcb141f-9288-4ce2-82bc-b1d961e7bc4f_20250507T14:39_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, [PII], I'm just trying to find out uh what is I had submitted a claim and I'm just trying to find out what's going on with the claim.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, so you're the insured and you're needing to check a claim status for yourself, is that correct?
[CUSTOMER][NEUTRAL] Yes, yes, yes, ma'am.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yeah, I can help you with that. And who am I speaking with, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] I'm sorry, [PII], did you say your last name is [PII]?
[CUSTOMER][POSITIVE] Yes, ma'am, [PII] like the phone keeps cutting out.
[AGENT][POSITIVE] OK. Thank you and
[AGENT][NEUTRAL] And your callback number, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, and your policy number?
[CUSTOMER][NEUTRAL] 252-238-3.
[AGENT][NEUTRAL] OK, Ms. [PII], thank you. Give me a couple of moments please to get your information pulled up, then I will have to verify several things with you first for security and also any information that is provided would be a verification of benefits and not a guarantee of payment. So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And then also your home mailing address.
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] My home address is [PII].
[AGENT][NEUTRAL] What is your zip code for your PO box?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. The phone number that we have for you is the same as the one you gave me, so that is your best contact number, is that correct?
[CUSTOMER][NEUTRAL] Yeah, that's fine.
[AGENT][POSITIVE] Thank you and lastly your email address please, Ms. [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you very much, and I do see that you are also set up in our portal, the online service center.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I do see that we reviewed the most recent claim that was reviewed, which you can also see this in the online service center.
[AGENT][NEUTRAL] Um, let's see. It was claim number 3597555. Is this for chemotherapy?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, alright, so I can see that this was denied. Let me look at the reason behind it. OK, so the, the remark on this most recent claim that was processed on [PII] states the policy maximum for chemotherapy, radiation therapy for the benefit period has been met.
[CUSTOMER][NEUTRAL] And what's the benefit period because I thought it.
[CUSTOMER][NEUTRAL] Uh, I thought it was, it, it went from April to April.
[AGENT][NEUTRAL] OK, so give me just a moment.
[AGENT][NEUTRAL] And look at some
[AGENT][NEUTRAL] I'm gonna look at your previous policy number.
[AGENT][NEUTRAL] OK. So this, OK, so it shows that your last chemo treatments started, it appears [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, I just
[CUSTOMER][NEUTRAL] OK, so what I'll look at, I went off of the last time that they, uh, I did a claim was uh.
[CUSTOMER][NEUTRAL] Back in April, [PII]. They didn't pay the claim until, well she said it was exhausted from 425 24 to 425 25.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Give me one moment to look.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it shows that the claim that we processed back in August for dates of service [PII].
[CUSTOMER][NEUTRAL] Mm, I, I don't see that.
[AGENT][NEUTRAL] Does show that the maximum when we pay that claim.
[AGENT][POSITIVE] That maxed out the benefit.
[AGENT][NEUTRAL] For
[AGENT][NEUTRAL] That benefit period when we process the claim, again, the chemo treatment date shows [PII] and that claim was processed in August.
[CUSTOMER][NEUTRAL] That was for the direct deposit was [PII], is that what you're talking about?
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] I don't see that. I'm only looking, I well I went back and looked at the claim back for.
[CUSTOMER][NEGATIVE] Uh, I don't even see the date on it now.
[CUSTOMER][NEUTRAL] Oh, OK. It was saying from 170 to 170.
[CUSTOMER][NEUTRAL] And that's when they paid out the whatever 1800.
[CUSTOMER][NEGATIVE] But it, and then on down on that same plane, it's telling me the date that it was exhausted. So it's telling me [PII] 24 to 42525. So that had me thinking I couldn't submit another, well, the last person I talked to told me I couldn't submit a claim until [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, this shows.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Let me look.
[CUSTOMER][NEUTRAL] I, I just go off of the papers that they send me. I don't know.
[AGENT][NEUTRAL] Alright, hold on.
[AGENT][NEUTRAL] Um, on your explan, let's see.
[AGENT][NEUTRAL] So what I can do is I can transfer you over to someone in the.
[AGENT][NEUTRAL] Claim support area to look to verify that date. I'm going on based on the notes that are on here because um on the claim that we processed where we paid 18,200.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm, yeah. And it had a exhaust bay of
[AGENT][NEUTRAL] The remark on that explanation.
[AGENT][NEUTRAL] Well, it says that it has been exhausted.
[AGENT][NEUTRAL] For this benefit period. Again, that was the claim that was processed for a July date of service, but it was processed back on [PII].
[AGENT][NEUTRAL] And it looks like.
[CUSTOMER][NEUTRAL] No, I just look at what it.
[AGENT][NEUTRAL] I'm OK. I don't, uh, so you're saying on your information that you have from APL, Ms. [PII], it has dates on your explanation of benefits because I'm looking at that.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It has
[CUSTOMER][NEUTRAL] It has a date on what they sent me showing that uh when the claim was exhausted, and it said uh it went from [PII] to [PII]. So when I called them, she was like, well you can't submit a claim till [PII].
[AGENT][NEUTRAL] OK. I'm, what's the claim number that that information is on that it states those dates?
[CUSTOMER][NEUTRAL] Oh, not my thing.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] So I can look at that specifically.
[CUSTOMER][NEUTRAL] Let me see if I can get back to it. I go in and out so much it's cutting out. Uh, looks like this claim num you you need the claim number?
[AGENT][NEUTRAL] Yes, ma'am, uh huh, that has that remark on it. Now, the claim number that gives you those dates of April.
[CUSTOMER][NEUTRAL] The policy number?
[CUSTOMER][NEUTRAL] Oh, OK, the claim number is 343495349.
[AGENT][NEUTRAL] OK, let me look at that.
[AGENT][NEUTRAL] And locate that claim number.
[AGENT][NEUTRAL] It takes just a moment to get this information, Ms. [PII] loaded up for me, so please bear with me. Thank you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Cause I can only, I don't see that full remark with dates on it on one of my screen, so I'm just going about it a little differently.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yeah, what they sent me, it was a page 1 and a page 2. So on page 2, that's where it shows, it shows that.
[AGENT][NEUTRAL] Uh-huh, right.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I do, let's see.
[AGENT][NEUTRAL] OK. So yes, ma'am. So now I'm going about it a little differently. I do see that remark, so give me just a second.
[AGENT][NEUTRAL] All right, and let me get back to your other policy number. So, one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it's showing that the chemotherapy that you submitted this claim for that we just processed, it hasn't.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It has a treatment date of [PII].
[AGENT][NEUTRAL] So that would have still been in that window of the benefits being exhausted.
[CUSTOMER][NEUTRAL] OK, let me
[CUSTOMER][NEUTRAL] 4
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] So I would have had to, so I can't really submit a claim, I guess, till May.
[AGENT][NEUTRAL] Yeah, after [PII]. Your service, not, not just submit the claim, but the dates that you receive your chemotherapy.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh, OK. I thought it was after, but.
[AGENT][NEUTRAL] Would have to be after [PII]. See, on your what you benefit period, [PII] has been exhausted.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, so you're saying I needed to, I should have waited till May I guess and submitted a claim.
[AGENT][NEUTRAL] Well, it's not just May. If you had a treat, even if you submitted your claim in May, but your treatment date was before [PII], it would have still been denied for that same reason that your benefit had been exhausted.
[CUSTOMER][NEUTRAL] I'm guessing that's, well.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] The treatment date had to be after [PII].
[CUSTOMER][NEUTRAL] OK, I'm trying to get back over here and look at the.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] You see what I'm saying. Your treatment began in April, so it would have [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it would have to be after [PII].
[CUSTOMER][NEUTRAL] OK. Oh,
[CUSTOMER][NEUTRAL] OK, well, let me, OK.
[CUSTOMER][NEUTRAL] Let me see. OK. So I did the treatment like [PII] or something, so it would have to be after April. OK. All right. I just have to.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] After [PII].
[CUSTOMER][NEGATIVE] I just have to come up off another $900 and wait for them to, I guess, yeah, that's the only reason because it's costing me so much every month to do my medication.
[AGENT][POSITIVE] Oh goodness.
[AGENT][NEUTRAL] Uh, yes.
[AGENT][NEUTRAL] I know it is. And I'm sorry, I know it's a very expensive thing. Personal experience, I, I do understand, so.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So you think that's the problem cause I mean, I, I can go ahead and try to buy me another one, but
[AGENT][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Because you're, yes, you had exhausted all your chemotherapy benefits.
[CUSTOMER][NEUTRAL] OK, that's that's.
[AGENT][NEUTRAL] For any dates between [PII] through [PII].
[AGENT][NEUTRAL] So for treatment
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Any, you know, your benefit year would start over after [PII], but that is treatment date, not just filing the claim date.
[CUSTOMER][NEUTRAL] OK, so we may.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, so I just ordered my medication, so maybe I'll be good if I do it submit it for May. I don't know. I'm just, the APL has changed a lot. I used to didn't have these many problems with it.
[CUSTOMER][NEUTRAL] But OK, I'll, I'll try again.
[AGENT][NEUTRAL] OK. Well, is there anything else, Miss [PII] that I could help you with this morning?
[CUSTOMER][NEUTRAL] No, ma'am. That'll be all.
[AGENT][POSITIVE] All right then. Well, thank.
[CUSTOMER][NEUTRAL] And see, when I called them just a few weeks, OK, that's fine. I, I won't worry about it. OK. I was just saying when I called them a few weeks ago, they had denied the claim and they said they denied it because I didn't send nothing showing what the medication was and on the explanation of benefits, the uh, the, the company doesn't put the name of the medication. They just put some numbers on there.
[AGENT][NEUTRAL] No, go ahead. No, ma'am.
[AGENT][NEUTRAL] Go ahead.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm, mhm. I could say we're.
[CUSTOMER][NEUTRAL] So they told me to send in something showing the name of the prescription, so I sent in 2 more 3 more papers.
[CUSTOMER][NEUTRAL] So, but OK, so she's telling me that I'll just wait and.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] No, that is correct.
[AGENT][NEUTRAL] See, there's certain things, there's certain pieces of information that we are required by law to have machines to fully review a claim. So yes, I can see where it was initially denied because we needed more information and then once we had everything is, is when the full review was completed.
[CUSTOMER][NEUTRAL] Right, I understand, yes.
[CUSTOMER][NEGATIVE] OK, and I don't know why they don't put the name of the medication on there. And then when they deny the claim, they don't tell me why they denied. They just say it's denied and I have to try to call in and find out what's going on. They don't send nothing telling me why they denied it.
[AGENT][NEUTRAL] Mm, OK.
[CUSTOMER][POSITIVE] OK, well thank you very much.
[AGENT][POSITIVE] Well, you are certainly very welcome. And again, if that is all I can help you with, thank you so much for calling APL and I hope that you have a very nice day.
[CUSTOMER][NEUTRAL] OK, you too.
[AGENT][POSITIVE] Thank you. Bye-bye.