AccountId: 011433970860
ContactId: eac97c35-1c71-4d31-98f5-942446a39d25
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1068900 ms
Total Talk Time (AGENT): 265102 ms
Total Talk Time (CUSTOMER): 428268 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.1, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/04/eac97c35-1c71-4d31-98f5-942446a39d25_20250204T16:33_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I need to get somebody to walk me through.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] A claim that was just that was processed.
[CUSTOMER][NEUTRAL] And do the payout.
[AGENT][NEUTRAL] OK, let's take a look at the claim. Do you have your policy number or the claim number?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah, the policy number is 2533255.
[AGENT][NEUTRAL] OK, let me pull this up here. Give me just a second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what's the name on the policy?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] And date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And then I just need to verify the address and email address on file.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then what, what else did you need?
[AGENT][NEUTRAL] Uh, just the email address.
[CUSTOMER][NEUTRAL] Um, it's uh [PII].
[CUSTOMER][NEUTRAL] [PII] or [PII] and [PII].
[AGENT][POSITIVE] All right, thank you for that.
[CUSTOMER][NEGATIVE] I'm having a hard time understanding.
[CUSTOMER][NEUTRAL] It's based off of the
[CUSTOMER][NEUTRAL] Her cancer insurance stuff that I'm looking at on, on what pays out.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And none of this is really matching up. I mean, there's no
[CUSTOMER][NEUTRAL] I don't know we've only been paid out other than the first initial.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Diagnosis
[CUSTOMER][NEUTRAL] Um, $3900 and then they just processed another one today for $700 but there's
[CUSTOMER][NEUTRAL] [PII], there's
[CUSTOMER][NEGATIVE] A quarter million dollars worth of claims on this, and they're only paying $735.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Not sure what it is that they're.
[CUSTOMER][NEGATIVE] I haven't been, been reimbursed for any of my travel. They're not paying for my.
[CUSTOMER][NEUTRAL] We've been up here since [PII].
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] In the hospital.
[CUSTOMER][NEUTRAL] Doing all kinds of treatments, cancer treatments, chemos.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] She's really, she's really sick and dying.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] But this policy, this policy is not paying anything, I mean.
[CUSTOMER][NEUTRAL] I don't understand what the
[CUSTOMER][NEUTRAL] point of having a cancer policy if they're paying $735 on $250 million.
[AGENT][NEUTRAL] On a larger claim.
[CUSTOMER][NEUTRAL] Work
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] On the
[CUSTOMER][NEUTRAL] And that's just, that's, and then there's 2 more that they haven't even.
[CUSTOMER][NEUTRAL] Looked at, but the one below that, from the [PII] was dated on [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] That one says process.
[CUSTOMER][NEUTRAL] But $0.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] I don't know if on this.
[CUSTOMER][NEUTRAL] This one that they're paying me out, I mean, that's the one with the huge bulk of the.
[CUSTOMER][NEUTRAL] She hasn't got paid for any of her chemo treatments.
[CUSTOMER][NEUTRAL] Like I said, there's $3000 in hotel rooms that
[CUSTOMER][NEGATIVE] I've had to pay out of my pocket. We're out of money.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] I'm stuck 8 hours from home, no jobs.
[CUSTOMER][NEUTRAL] I'm just trying to get, you know, what's owed to pay to, so.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] While we
[AGENT][NEUTRAL] [PII], did you, did you send in the authorization form, the third party thing, um, that we had sent out to you? Did you get that ever sent back to us so we can like disclose information?
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Yeah, it's you have all that you have the power of attorney, the form, all that's already been uploaded weeks and weeks ago.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I guess back when uh before the one for the 3950 was paid somewhere in that time frame, I've sent all that in.
[AGENT][NEUTRAL] [PII], OK.
[CUSTOMER][NEUTRAL] And it's been, yeah, and it's been verified and stuff that y'all received it, so.
[AGENT][NEUTRAL] OK, 1 2nd.
[CUSTOMER][NEUTRAL] But yes, it's all in there.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Maybe I'm just an idiot when I read this.
[CUSTOMER][NEUTRAL] Summary of benefits, you know, like the.
[CUSTOMER][NEUTRAL] Chemo is, she's on the plan too.
[CUSTOMER][NEUTRAL] He level 3 chemo benefits for 12 months is 15,000. She's already had two treatments, but no payment on it.
[AGENT][NEUTRAL] Mm, OK.
[CUSTOMER][NEUTRAL] So I don't know how they, you know, like, how do they determine.
[CUSTOMER][NEUTRAL] It just says 15,000 per year, but is that
[CUSTOMER][NEUTRAL] A percentage of each treatment, is it?
[CUSTOMER][NEUTRAL] I mean just looking at this.
[CUSTOMER][POSITIVE] Benefit stuff that everything is paid. I mean, there's.
[CUSTOMER][NEUTRAL] You know, follow up diagnostic testing that we haven't got paid for the medical imaging for 500, we haven't got the
[CUSTOMER][NEUTRAL] And then I have questions on the surgery, so she's had two surgeries.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 11 was a major surgery, the colonoscopy, or I mean the, the colostomy surgery.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Um, she was in the hospital for almost
[CUSTOMER][NEUTRAL] 1012 days for that.
[CUSTOMER][NEGATIVE] None of that's been paid.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] So yeah it sounds like we need I need to get a claims examiner on the phone that actually processes the claims and can go over these with you like in in detail um you know I can look at the claim and kind of give you what it states on the explanation of benefits but you already have that information so um let me.
[CUSTOMER][NEUTRAL] Yeah, I have it in.
[CUSTOMER][NEUTRAL] Front of me. I just understand uh there's, there's one bill out of this that has already been. I know I have some more from the hospital on my portal that I've been sending that I've been sending in also that says pending insurance.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But it, but it does have the.
[CUSTOMER][NEUTRAL] The uh medical code that y'all need for each procedure that they did.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You know, the little medical code that y'all have to have that has that on there, so.
[AGENT][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] But, but the one for the $191,000.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] That's on there. I mean, I just can't.
[CUSTOMER][NEUTRAL] I don't guess I'm comprehending why.
[CUSTOMER][NEUTRAL] Out of
[CUSTOMER][NEUTRAL] You know, over $200,000 worth of
[CUSTOMER][NEGATIVE] Medical bill or cancer stuff, they're only paying her $700.
[AGENT][NEUTRAL] Right, OK, yeah, let me, let me get a claims examiner on the line that processes these and they're gonna be um better equipped to tell you exactly why it was denied and if there's anything that was maybe missing then they can give you detailed information as far as what to submit so you're not kind of in this loop of not understanding kind of what's going on OK?
[CUSTOMER][NEUTRAL] I mean,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, cause it's been going on for 2 months and so it, it's uh.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I mean this is the only thing we got besides the disability and stuff that that we're trying to get with living in a bedroom with.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Friends were, I mean, I don't.
[AGENT][NEUTRAL] All right, um, let me, yeah, let me get somebody on the line. [PII], is the [PII] a good callback number if anything happens? OK.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, that's my cell phone number.
[AGENT][NEUTRAL] OK. Um, place you on a brief hold. One moment.
[CUSTOMER][NEUTRAL] Thank you, ma'am. You are on hold.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Where is she saying this authorization.
[AGENT][NEUTRAL] Did you call claim oh my.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Alright, we're just gonna call this claims for.
[AGENT][NEUTRAL] No, that's OK.
[CUSTOMER][NEUTRAL] Sing
[AGENT][NEUTRAL] Where's the third party authorization.
[CUSTOMER][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII] over in customer care. How are you doing this morning or this afternoon, whatever it is.
[CUSTOMER][NEUTRAL] F
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][NEUTRAL] I'm good um I have an insured on the line and has some questions about claims is that something that you can help with?
[CUSTOMER][NEUTRAL] Sure, what's the policy number?
[AGENT][NEUTRAL] Policy number is 2533255.
[AGENT][NEUTRAL] Should come up as [PII].
[CUSTOMER][NEUTRAL] OK, and what is her question?
[AGENT][NEUTRAL] So
[AGENT][NEGATIVE] I'm speaking with [PII] and I see in the notes that there's a 3rd party on file, and I was trying to find the 3rd party first of all, I can't even find it. Do you see it?
[CUSTOMER][NEUTRAL] OK, let me take a look. Who is he identifying himself as like the broker?
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] He's the, no, he's the spouse. I'm sorry.
[CUSTOMER][NEUTRAL] OK, let me see if we have it.
[AGENT][NEGATIVE] I looked in on base, but maybe I'm just not looking in the right spot.
[CUSTOMER][POSITIVE] Yeah, we have one. I can share my screen. Do you mind? I can share my screen and I can tell you how to get to it.
[AGENT][POSITIVE] Yeah, absolutely.
[CUSTOMER][NEUTRAL] Oh, you're not on teams. Hold on.
[AGENT][NEUTRAL] No, I'm not, but if you tell me, are you in on base?
[CUSTOMER][NEUTRAL] Yeah, I'm in, no, I'm not in on base. So if you go to this screen and this is what the screen is called CLHIP, which is the HIPAther release.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And then you'll key in that policy number.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] And then it shows his name and when it began and when it will end.
[AGENT][POSITIVE] Got you, girl, thank you so much for that.
[AGENT][NEUTRAL] Um, OK, so he is a little, he's a little confused, doesn't understand if you look in the claims.
[AGENT][NEUTRAL] The recent one that was just paid today or yesterday [PII] it's claim number 355.
[AGENT][NEGATIVE] 8957 he doesn't understand why it just paid $700. We went over some of the like denials.
[CUSTOMER][NEUTRAL] OK, let me take a look.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] But I'll be honest, he's very stressed out, like he's had some claims that hasn't paid. It sounds like.
[AGENT][NEUTRAL] His wife's not doing well and he's really just trying to understand why it's only paying this much and he was going kind of on all these other amounts and said, you know, hey, it may be better if somebody processes claims kind of goes over your concerns with you.
[CUSTOMER][NEUTRAL] So let me take a look, so we did pay it looks like we paid the.
[CUSTOMER][NEUTRAL] Surgery, but on the chemo, we still need the EOB. This policy, the state is
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] [PII], yeah, it's based off actual charges. So he hasn't submitted the actual EOB which is from their major medical insurance carrier in order to consider the chemo. It looks like that's missing.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Let me double check and see what else.
[CUSTOMER][NEUTRAL] Cause see from what he sent in, it just looks like a
[CUSTOMER][NEUTRAL] Billing statement. I don't see any EOBs in any of this. And let me see what else they, they had inquired on this EOB.
[CUSTOMER][NEUTRAL] Mm, so 119.
[CUSTOMER][NEUTRAL] Will you pay anything? OK, they pay anesthesia and
[CUSTOMER][NEUTRAL] They already paid the facility. OK, so that's what that was processed as a duplicate cause those are already paid out. They, they only get a max of $150 on the outpatient drug per month. So that's why that exhausted.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, but you can send it to me. I can't explain it to him.
[AGENT][POSITIVE] OK, thank you so much. I appreciate you. I hope you have a good day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][NEUTRAL] Here it comes.
[CUSTOMER][NEUTRAL] Claims department, this is [PII].