AccountId: 011433970860
ContactId: f3e87e00-0605-4a0b-a567-010e60824b00
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 3826629 ms
Total Talk Time (AGENT): 1444904 ms
Total Talk Time (CUSTOMER): 975888 ms
Interruptions: 8
Overall Sentiment: AGENT=0.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/f3e87e00-0605-4a0b-a567-010e60824b00_20250408T18:40_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, how are you? Um, I'm having trouble accessing my account online. um, I think that I need to reset the password, but, uh, it won't let me.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Oh sure, I can assist you with that no problem. Um, may I have your name and a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, of course. The, the name is [PII]
[CUSTOMER][NEUTRAL] And the phone number would be [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK. Thank you. And may I have the policy number or the group number?
[CUSTOMER][NEGATIVE] Um, I do not have it with me.
[AGENT][NEUTRAL] OK. Uh, is this your personal policy, Mr. [PII], or you're calling about, you're calling from a group?
[AGENT][NEUTRAL] Representing a group.
[CUSTOMER][NEUTRAL] Yeah, it's a, it's a personal policy.
[AGENT][NEUTRAL] Personal. OK. All right, um, let me go ahead and do a name search. OK, one moment.
[CUSTOMER][POSITIVE] Yeah, no worries.
[AGENT][NEUTRAL] All right. What's the last name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] May I have your date of birth for security?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Thank you. And I need to verify the mailing address on file.
[CUSTOMER][NEUTRAL] OK. Um, so it would be [PII].
[CUSTOMER][NEUTRAL] Uh, the [PII].
[AGENT][POSITIVE] OK. Thank you, Mr. [PII].
[AGENT][NEUTRAL] Alright, so the reason that it's not letting you go in is because the policy is terminated, um.
[AGENT][NEUTRAL] So, um, it will not let you go in if the policy is terminated. This policy was terminated back in [PII]. Are you trying to send a claim?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Yeah, I actually, I submitted a claim not too long ago, uh, and I got a response and everything.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Um, yeah, I can check and see about that claim here. It's not gonna let you, um, go back to your account because it's terminated. Um, so let me just go ahead and
[CUSTOMER][NEUTRAL] OK, that's fine.
[AGENT][NEUTRAL] Look into this really quick one moment.
[CUSTOMER][POSITIVE] Yeah, no worries.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Was this for a uh pharmaceutical from CVS?
[CUSTOMER][POSITIVE] Correct, uh, soon to, yup.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] On
[AGENT][NEUTRAL] Let me look at the details of this claim. Do you mind holding for me?
[CUSTOMER][POSITIVE] Yeah, no worries.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me Mr. [PII]. OK, um, was this for chemo?
[CUSTOMER][NEUTRAL] Uh, immunotherapy, yeah, it's almost the same as chemotherapy.
[AGENT][NEUTRAL] Immunotherapy. OK. All right. And it was for [PII].
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So it was from uh [PII].
[CUSTOMER][NEUTRAL] [PII] to um yeah, pretty much [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Wait, no, no, no, hold on, uh.
[CUSTOMER][NEUTRAL] Let me think 2 seconds, um.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII], no, it, it has to be [PII].
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Right, that's, and that's also when I have the policy.
[AGENT][NEUTRAL] OK, so, uh, it looks like based on the information, it was [PII] and that's why it was denied because it was prior to that day. Um.
[AGENT][NEUTRAL] The effective date of the policy. That's why I'm trying to determine if we're just overlooking something or not, but um.
[AGENT][NEUTRAL] Let me look at this paperwork again.
[CUSTOMER][POSITIVE] Yeah, no worries, um.
[AGENT][NEUTRAL] Yeah, this one is [PII]. So if you meant to send the [PII], uh, you probably need to get a copy of the [PII] and send it again. This one is [PII].
[CUSTOMER][NEUTRAL] OK, uh, but, uh, actually, no, it, it should be [PII].
[CUSTOMER][NEUTRAL] Alright, give me 2 seconds and let me just verify the information on my end, um.
[AGENT][NEUTRAL] OK, OK, sure.
[CUSTOMER][NEUTRAL] Alright, I'll put you on hold for 2 seconds.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure, sure. Go ahead.
[CUSTOMER][NEUTRAL] OK, so it does seem that it's correct that it was [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, for the policy number though, I think that might be the, the problem. The policy number is the one that ends in 189.
[AGENT][NEUTRAL] 1898. No, it was sent to the wrong policy. OK, um.
[CUSTOMER][NEUTRAL] OK, so that's, that's it. So the policy number should be 01220189.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] OK. So, um, if you can just go ahead and resend it, but you're not gonna be able to send it online no more. You can fax it or mail it. Is that OK?
[CUSTOMER][POSITIVE] Yeah, yeah, I can mail it to you.
[AGENT][NEUTRAL] OK. Um, yes. Together with that, um, if you can send in the copy of the explanation of benefits from the primary insurance, uh, so we can have a full claim because it looks like you tried to send this in the past, but we were missing the explanation of benefits from the primary insurance. So if you can send us that information together with this um
[AGENT][NEUTRAL] With this receipt we can go ahead and work on that for you, OK?
[CUSTOMER][NEUTRAL] So yeah, just uh clue me in a little bit uh on the what do you mean by the primary insurance because the primary insurance should be um uh combination of Blue Cross Blue Shield with uh the Texas teachers retirement system and they hire, uh.
[CUSTOMER][NEUTRAL] Caremark or Carescripts, I guess, to be the uh provider, right? That the one that takes care of the insurance. So the form that I submitted to you guys.
[AGENT][NEUTRAL] Mm
[CUSTOMER][POSITIVE] Should be the uh explanation of benefits and that was just an example of um something they sent me really quick.
[CUSTOMER][NEUTRAL] However, uh, I also sent the um,
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I guess the billing that happened through Caremark, um.
[CUSTOMER][NEUTRAL] Throughout, you know, the year of [PII].
[AGENT][NEGATIVE] OK, what, what I have here, and this is what I'm looking at that um you sent in recently and it was put on the wrong one, OK. I got only 2 pages um and the second page is the statement of patient costs um and then the first page is just.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, just.
[AGENT][NEUTRAL] Information about you, um, this request for personal protect health information. So that's all we got that letter and then the, the second letter, which is just a um breakdown of the charges or the doctor charges and all that, the cost, um.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] So yeah, so that what what else would be missing because I mean the.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, the
[CUSTOMER][NEUTRAL] Uh, immunotherapy coming from CVS Caremark, right? And since it's a specialty in medicine, uh, they do it through this, uh, program.
[AGENT][NEUTRAL] So it's not being paid by your major medical?
[CUSTOMER][NEUTRAL] Um, I, well, it is the contract that they might have, uh, with, um.
[CUSTOMER][NEUTRAL] Scripts [PII].
[AGENT][NEUTRAL] They don't run this through your, like, um, you said Blue Cross was one of your insurance, they don't run it through Blue Cross.
[CUSTOMER][NEUTRAL] Mm mm.
[AGENT][NEUTRAL] No, OK.
[CUSTOMER][NEGATIVE] Mhm because they don't because they don't provide Blue Cross Blue Shield doesn't provide um.
[CUSTOMER][NEUTRAL] I guess, uh, drugs or prescription drugs.
[AGENT][NEUTRAL] Mm, OK. Um, hmm.
[AGENT][NEUTRAL] Let me see if this document that you sent in the past is the same thing.
[AGENT][NEUTRAL] I'm just gonna go ahead and pull one of your old documents, the ones that we were asking for the EOB for the explanation of benefits, OK, one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, yeah, yeah, no worries. Thank you very much.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] All right, OK.
[AGENT][NEUTRAL] OK, so this is the payment you're doing.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so this is payment is extra.
[CUSTOMER][NEUTRAL] Yeah, I'm here.
[AGENT][NEUTRAL] OK. All right, so I'm looking at the paperwork you said in the past and yeah, it was just a payment history, so, OK, I see the difference. OK.
[AGENT][NEUTRAL] So, um,
[AGENT][NEUTRAL] On the one that you sent recently that was put in the wrong policy, that may, may work um because it does say apply towards the deductible. Um, now, I only see the date of [PII] and [PII] listed on this one. So if you can get uh from [PII], which is the first one that you submitted on this policy back then when you try the first time in [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, if you can go ahead and get the same document, but starting on [PII], that might help with that payment, OK? So, um, just go ahead and send it in to with that policy, the [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, um,
[CUSTOMER][NEUTRAL] Just quick question, um, with that, um,
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] With, with what whatever benefit I have under the policy, it should cap at 20,000, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, let's see if it's 20,000. Let me look at the benefits on this one because it's gonna run through this one. So let me look at the benefits on this one.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I also need to check and see if there's any payout.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] All right, and this is not a guarantee of payment, just a verification of coverage and that's just a disclaimer. And here we go. OK, so it's 20,000 every 12 month period. OK, so, um, let me check and see if there's any payout. So let me go to claim history.
[CUSTOMER][POSITIVE] Yeah, of course, of course.
[CUSTOMER][NEUTRAL] You should have uh I believe yeah it's uh 20,000.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, so you have not had this benefit paid to you in the past.
[AGENT][NEUTRAL] OK. Um, all right, so yeah, that, that will be the benefit is 20,000 for 12 month period.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Yeah, so I mean if just with the uh information that you guys have right now that should meet the gap and uh all the other uh all the other months would not even apply so if you can just uh processing as it is right now um.
[AGENT][NEUTRAL] Well, we need
[CUSTOMER][NEUTRAL] And if you need that uh
[CUSTOMER][NEUTRAL] a reference for the annual total gross cost, um, if you go back to the CBS, the statement of patient costs at the very bottom right, it says for the period, um, that we were talking about, uh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] How much would be the annual total gross cost of of that and it would be the [PII].
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, I'm not really sure if that's what they based off. I don't, we don't, we don't process claim here. It goes to another department to be processed. Um, you can go ahead and just send that out to us and, and have us process that and see if that will be sufficient. Um, but yeah, it just needs to be sent to the correct policy.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] All right, um.
[AGENT][NEUTRAL] Because you send in the claim, we cannot move them because you send it electronically through to your account, um, and we cannot move them because you send them. Mhm.
[CUSTOMER][NEUTRAL] Right, and, and.
[CUSTOMER][NEGATIVE] And I don't have access to the account anymore you said it was terminated?
[AGENT][NEUTRAL] Uh no. Yeah, since it's terminated, once it locks you out, it will not let you go back in.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] When was it terminated, do you know?
[AGENT][NEUTRAL] Oh, it's terminated back in [PII], but I guess the last time that you went in to um put these claims or view the claim, it locked you out and from there it will not let you go back in because it's terminated. We can try, but uh.
[AGENT][NEUTRAL] I have, well, I have seen before this doesn't let them go in again. So let's try, um, you don't lose nothing by trying. OK, so let's see, let me go back to the new one. OK, let me get out of the old policy, go to the new one.
[CUSTOMER][NEUTRAL] Right, right, right.
[AGENT][NEUTRAL] Oh and it's a different group.
[AGENT][NEUTRAL] You probably don't have this one listed. I'm not sure. Let's see.
[AGENT][NEUTRAL] Was you able to see this policy when you went in the um online?
[AGENT][NEUTRAL] Portal
[CUSTOMER][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] It was OK, alright, let's see. um hm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Not giving me a number.
[AGENT][NEUTRAL] Let me pull this one maybe you will give me a number here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, yeah, there's one here. Let's see what we can do with this number.
[AGENT][NEUTRAL] 2306.
[CUSTOMER][NEUTRAL] Let's see.
[AGENT][NEUTRAL] active and uh what username are you using?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Can you use it all lower cases?
[CUSTOMER][NEUTRAL] Yeah, everything is lower case.
[AGENT][NEUTRAL] And when you click on um forgot password what message is it giving you?
[CUSTOMER][NEGATIVE] Uh, it's telling me that it's an invalid username or password.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Do you wanna go ahead and try it while you got me on the line and see if it will work? Um, OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, let me try again and we'll see.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEGATIVE] Yeah, it says invalid username or password, and whenever I try to reset the password.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, it does find my account.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Uh, but he won't send it to my mobile phone.
[AGENT][NEUTRAL] OK, uh, what about your email?
[CUSTOMER][NEUTRAL] Oh, hold on, I, I just.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] It just allowed me to let me try to do that pretty fast.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, so.
[CUSTOMER][POSITIVE] Alright, so it seems that I was able to change it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I'm in, OK.
[AGENT][POSITIVE] Oh, perfect. Wow. OK. I'm glad that worked. Um, yeah, usually it doesn't let you go back in.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK, so it seems that I have then 3, thank you very much. Uh, it seems, uh.
[AGENT][POSITIVE] Mm. You're welcome.
[CUSTOMER][NEUTRAL] Well, one, you have very good luck. You bring me good luck, but, uh, second, that I had 3 policy numbers.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yes. Uh-huh. You had three cancer. Um, one was with a different group number and then they switched groups and you have two other ones. Um, so I don't, can you see the 1220189 listed?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so yeah, if you can just go ahead and upload that claim to that number, um, we'll go ahead and process the claim.
[CUSTOMER][POSITIVE] OK perfect um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And everything else, what, what is the coverage for these policies?
[AGENT][NEUTRAL] But right now they're terminated, um, they were terminated back in [PII]. Um, the coverage on the most recent one, let me see what it was, uh.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, so this one had different types of benefits. Let me pull the benefit on this one.
[AGENT][NEUTRAL] And you can also view this information by double clicking the policy number. It should be in blue and it should give you like a PDF with all that information, but let me see if I can get it.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh yeah, it, it, it gives me a PDF for then um.
[AGENT][NEUTRAL] Mhm, yeah.
[CUSTOMER][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] And that will give you a breakdown of all your benefits. Mhm.
[CUSTOMER][NEUTRAL] Effective date in [PII].
[AGENT][NEUTRAL] OK, and the schedule is on the 2 page 21, starts your benefits.
[CUSTOMER][NEUTRAL] And it's
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so, oh well, it's just, it's.
[CUSTOMER][NEUTRAL] Yeah, so that's the last one, so that means that it just ended, yeah, in [PII].
[AGENT][POSITIVE] Yeah. Yeah, and it did have a lot of benefits, but yeah, it did include also that 20,000 for the 12 month waiting um for the 12 month period of chemo, radiation or immunotherapy, but it had like hormone therapy, it had surgical benefits, um, thetasis benefit, um.
[CUSTOMER][NEUTRAL] Yeah, but wouldn't that be treated as a um
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Because it said that it was a preexisting condition exclusion applied to it.
[AGENT][NEUTRAL] Mhm. Yeah.
[CUSTOMER][NEUTRAL] So that means that cancer was not covered by it?
[AGENT][NEUTRAL] No, it means that um basically if when there's a 12 month preexisting condition, which that's usually how it works, it means that um we will pay if they find a new cancer.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But it will not treat the one that you've been treating before.
[AGENT][NEUTRAL] After the 12-month waiting period. Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So you need to wait 12 months for this policy to start any type of um benefits to be paid.
[CUSTOMER][NEUTRAL] OK, yeah, so then.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] This very last one, the one that ends in 44, then it wouldn't apply, and that makes sense.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Now for um.
[CUSTOMER][NEUTRAL] The one that is 13.
[CUSTOMER][NEUTRAL] Let me see. That, that one has a coverage of
[CUSTOMER][NEUTRAL] OK, here it is.
[CUSTOMER][NEUTRAL] So it's uh actually.
[CUSTOMER][NEUTRAL] Current right now, um.
[CUSTOMER][NEUTRAL] The one that uh that ends in uh 30, so 25, 25, 9:30.
[AGENT][NEGATIVE] Oh yeah, that one was terminated when the group decided to terminate so it we was trying to get it started for the group, but they decided not to go with it and so it just, it was created but it was never activated.
[CUSTOMER][NEGATIVE] OK, so this one is not activated.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm, no, it, it, it was just created.
[CUSTOMER][NEUTRAL] And the one that would be the most relevant, um, I can't access them, which is the 189 um.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Policy
[AGENT][NEUTRAL] Mhm. And the 189 was good from [PII]. So that means that anything after [PII], which there was a gap in coverage right there, then uh there's not gonna be covered. So the ones that you're trying to send, I think they're for October.
[AGENT][NEUTRAL] Um,
[AGENT][NEGATIVE] And that one is not gonna be.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] It should be [PII], right?
[AGENT][NEUTRAL] Let me for.
[CUSTOMER][NEUTRAL] whenever it ended.
[CUSTOMER][NEUTRAL] See you
[AGENT][NEUTRAL] Um, that one, the one that ended recently before the one that was created and never active was from [PII].
[AGENT][NEUTRAL] To [PII], but between [PII] to [PII], there is no policy.
[AGENT][NEUTRAL] So if you need to um send in claims, it has to be prior to [PII].
[AGENT][NEUTRAL] No, the one that you sent in, uh, that was denied because it was, um, the Caremart was [PII], but you did submit some claims on [PII], and that's why I was saying if you can send the explanation of benefits for those ones, then we can go ahead and process those for you.
[CUSTOMER][NEUTRAL] Mm mm mm, yeah, OK, um.
[AGENT][NEUTRAL] So basically, the one for October and November, um, those are not gonna be paid because you didn't have an active policy during that time.
[CUSTOMER][NEUTRAL] Who, who, OK.
[CUSTOMER][NEUTRAL] Why was there a gap in coverage?
[AGENT][NEUTRAL] There is a change of groups, um, let me check and see if that's the same group or different group, bear with me.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me pull this up.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] I'm an ISC.
[AGENT][NEUTRAL] OK, so 11 was [PII] and the other one was.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Yeah, correct.
[AGENT][NEUTRAL] So there were two different, different groups.
[AGENT][NEUTRAL] So with [PII].
[CUSTOMER][NEUTRAL] So the one that was on [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, they stop on [PII].
[CUSTOMER][NEUTRAL] That one started on
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Wait.
[CUSTOMER][NEUTRAL] So there's a gap of a year uh between these policies.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Why did that happen?
[AGENT][NEUTRAL] Mm, not sure, but the group started again. Well, the other group that you started with started with us on [PII].
[CUSTOMER][NEUTRAL] Splendora, yeah, that was on [PII].
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I don't know if in that time.
[CUSTOMER][NEUTRAL] And you tell me that the, the previous 1, 18189 ended in uh
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] A year prior
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I, I'm not sure if they just decided to use a different company during that year and then they came right back to us or I'm, I'm not really sure what happened during that, that year, but yeah, it looks like you had a whole year without coverage.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, let me see.
[CUSTOMER][NEUTRAL] I should have those documents.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, that's 222.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Were any of the policies modified uh afterwards?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] None that I can see. I just see the changes of the policy product um in the group. That's all I see.
[AGENT][NEUTRAL] But it was basically because of a group change, not really a policy product change.
[CUSTOMER][NEUTRAL] Yeah, OK, I, I, I found the certificate of the policy for 189.
[CUSTOMER][POSITIVE] And it effective
[CUSTOMER][NEUTRAL] The effective date.
[CUSTOMER][NEUTRAL] Was, um, the policy effective date was from [PII].
[AGENT][NEUTRAL] [PII], [PII] you had a um
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You had a secondary policy, not a cancer policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, yeah, the certificate, the effective date was from [PII].
[AGENT][NEUTRAL] Yeah the cancer policy.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And that should have covered all the way to
[CUSTOMER][NEUTRAL] Um, [PII], when I, whenever I change my job.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I'm not I'm not really sure about that. Um, I'm looking at the same information you're looking at the only difference of what you're looking at and I'm looking at is because I see a termination date. I don't know if you can see that termination date. It's not gonna be in the certificate. It's gonna be on the policy itself. Yeah, the policy, um, is indicated that it was terminated [PII] and your new policy didn't start until [PII] with the new group.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that
[CUSTOMER][NEUTRAL] And we didn't have anything prior to that?
[AGENT][NEUTRAL] Mm, no.
[AGENT][NEUTRAL] There's nothing in between those two.
[AGENT][NEUTRAL] And if you believe or if you think that may be an error, you probably need to get in contact with um [PII] ISD.
[AGENT][NEUTRAL] And see where, um, yeah, what they have you down for if you was terminated with them on um [PII] or was it [PII] if they have anything to prove that you was listed on that group during that year or if they were with us, I don't know. Let me see if it will tell me if that group was with us during that year.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, if you, if you guys had um any other uh policies with them.
[AGENT][NEUTRAL] You know, and
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Uh, yeah, it looks like they decided to go away on September. Yeah, [PII] was the last year for [PII].
[AGENT][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] All right, so I will need
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] Yeah, that's, uh-huh, yeah.
[AGENT][NEUTRAL] So 22
[CUSTOMER][NEUTRAL] Which
[CUSTOMER][NEUTRAL] OK, with in that regardless that should be fine.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Because the so the payments let me see um.
[AGENT][NEUTRAL] Yeah, it, it should be fine because, yeah, you did have some claims that was waiting on the explanation of benefits for [PII] on the old policy, so yeah, and there's no timely filing limits. You just need to submit that information.
[CUSTOMER][NEUTRAL] How far that state so.
[CUSTOMER][NEUTRAL] Oh yeah, yeah, they
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah, um, and with the payment history that I submitted from CBS Specialty, the account activities from, uh, uh, [PII], so that should be covered, uh, for.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That the biggest bulk of them, and yeah, the charge was $102,000.
[CUSTOMER][NEUTRAL] So that yeah that that should meet the cap even for.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEGATIVE] Yeah, for this, for in the [PII] um policy now I see why I didn't um submit that claim under 189 and it's because it won't let me to uh do that.
[CUSTOMER][NEUTRAL] Under the portal.
[CUSTOMER][NEUTRAL] Would you be able to submit that 189 um.
[AGENT][NEUTRAL] You will not then yeah.
[CUSTOMER][NEUTRAL] Just exacting the the the documents that I sent.
[CUSTOMER][NEUTRAL] Uh, but they just need to be redirected to the right policy number, but I can't do it online for some reason it won't allow me to.
[AGENT][NEUTRAL] OK, uh.
[CUSTOMER][POSITIVE] It just allows me to select the other two.
[AGENT][NEUTRAL] It may be because it's an old policy that was terminated back in [PII] and that's probably the reason it's not letting you. Um but um
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, what I was telling you in the beginning, Mr. [PII] is the information that I have here, um, the statement of patient costs only lists the dates of [PII] and [PII]. Uh, it says for the period of [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So since the date of service or the period date was [PII], that one is gonna be more than likely denied. So we need anything that starts like.
[AGENT][NEUTRAL] In [PII], like the first claim that it was sending, if you go to that old policy, you click on it, you, I don't know if you're able to see the claims that's been processed.
[AGENT][NEUTRAL] Do you see any claims under that old policy? OK.
[CUSTOMER][NEUTRAL] Uh, let me go back.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So the claim numbers.
[AGENT][NEUTRAL] If you see the claim number 3343345.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] OK. So that one.
[CUSTOMER][NEUTRAL] It's getting the file right now.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, that one is saying that it's for chemotherapy starting on [PII]. And for that one, we was requesting the primary explanation of benefits which is
[AGENT][NEUTRAL] Something like what you just send in just the date of service needs to be [PII] or [PII]. So if you can send that information in, we'll go ahead and reprocess this claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Yeah, no, the only problem is that I don't think they keep records from.
[CUSTOMER][NEUTRAL] Back then, so far back, um.
[CUSTOMER][NEUTRAL] However, yeah, OK, I see why there's one file missing.
[CUSTOMER][NEUTRAL] In
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] OK, yeah, I'll I'll submit the.
[CUSTOMER][NEUTRAL] Payments that were made on the right date. That's why it it says that it has no files interesting.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's because it's been a long time and usually the system will allow you to either submit or view or get printouts or anything like that, but 12, I think it's 12 months, not more than 12 months.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So basically after the 12 months, it's just you're not gonna be able to get documents or submit documents. So that is the problem that you're having on that policy because this is such an old policy. 22 it's been like 3 years. Yeah, and that's the reason it's not letting you. But um if you can just go ahead and do everything paper, um, we'll go ahead and process this for you. So if you can just go ahead and fax or send this claim by mail.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] We can go ahead and process, but it has to be sent to us because we don't have anything for that date of service of [PII] that I can move to this policy.
[AGENT][NEGATIVE] The one we have is from October, so it's just not gonna work.
[CUSTOMER][NEUTRAL] Mhm, um.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Next
[CUSTOMER][NEUTRAL] Uh, select files. OK, I'm just gonna upload the document really fast to make sure that you receive them and you can see them and.
[AGENT][NEUTRAL] OK
[CUSTOMER][POSITIVE] That will make things easier.
[AGENT][NEUTRAL] You're gonna upload them to where?
[CUSTOMER][NEUTRAL] To the portal, um, to the claim.
[AGENT][NEUTRAL] To what policy?
[CUSTOMER][NEUTRAL] Um, since it won't let me select the policy, what I'm just gonna do is I'm gonna say that it's not listed on the, uh, policy types or claimants, so I just input the name uh of the claimant of the insurance and date of birth, uh, manually.
[AGENT][NEUTRAL] OK. I'm not sure if that's gonna work, but you can try that again, that goes to a different department. And once they, they get the claim, they'll go ahead and process.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Maybe you want to put a note in that claim saying to please see policy blah blah blah, and so they know that it should be on that other policy instead of that one. I don't know if there's any way you can just add a note to it.
[CUSTOMER][NEUTRAL] Yeah, uh, I'll add the copy of the claim.
[CUSTOMER][NEUTRAL] Um, that was relevant to it.
[AGENT][NEUTRAL] OK. Yeah, so they know that it's not for this one, it's for another policy that you have.
[CUSTOMER][NEUTRAL] Alright, so that shouldn't.
[CUSTOMER][NEUTRAL] OK, so yeah, it created a new one it's uploading.
[CUSTOMER][NEUTRAL] Now let's see if you can see the files.
[CUSTOMER][NEUTRAL] Yeah, so you should be able to see it now, um, the this new claim that I just, uh, uploaded. So if you look at the very first document is submit the payments.
[CUSTOMER][NEUTRAL] Uh, that has a payment history.
[CUSTOMER][NEUTRAL] From
[CUSTOMER][NEUTRAL] [PII] so I should be able to care uh to cover the bulk.
[AGENT][NEUTRAL] What, where did it
[AGENT][NEUTRAL] Where did it go to?
[CUSTOMER][NEUTRAL] It's in the under the claim, so you probably have to uh um refresh the.
[CUSTOMER][NEUTRAL] Page and if you go to under my claims.
[AGENT][NEUTRAL] OK. Your, yours is not gonna be the same system. It's a different system. OK. um, what policy is under? What policy number is under?
[CUSTOMER][NEUTRAL] The new claim is.
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah.
[CUSTOMER][NEUTRAL] It's the confirmation number is OSC 96336.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me try.
[AGENT][NEUTRAL] Mm.
[AGENT][POSITIVE] Yes research.
[AGENT][NEGATIVE] I no.
[AGENT][NEUTRAL] And this is uh this is the same information that was submitted before. Let me see what's the other one.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, I will have to let an examiner look into it um because this is the same information that was submitted before that we, um, we requested the EOB, yes, the same information it didn't change at all. And then the information that you're sending on the statement of cost is the same one which is the [PII], and you say you don't have a way of getting any.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, but it's just a representative, uh, example of, uh, for example, the cost, but.
[CUSTOMER][NEUTRAL] Regardless, it's with the same, uh, I guess insurance and the same um
[CUSTOMER][NEUTRAL] Submissions of the refills and with the same doctor, same patient.
[AGENT][NEUTRAL] Yeah, but what I'm saying, uh, OK, it has to be, it has to be processed by examiner because I, I don't process claims, but I'm looking at the information and I see right off the back.
[AGENT][NEUTRAL] The information is not gonna match. Why? Because the date of service doesn't match. The date of service that um the period, [PII], that period is not on the paperwork you're sending. The period that you're sending or the paperwork you're sending is for [PII]. So those two are not related.
[AGENT][NEUTRAL] Just because of the date of period of service or period of um.
[AGENT][NEUTRAL] Where you got the, the medicine.
[AGENT][NEUTRAL] So I don't know if you can go back to CVS Caremarkt and see if they have anything prior.
[AGENT][NEUTRAL] For the period of um [PII], but that's the one we're gonna need.
[CUSTOMER][NEUTRAL] So the pharmacy name uh is CVS Specialty Caremark.
[AGENT][NEUTRAL] I'm looking at the what you submitted to us, OK? So I'm looking at page 8.
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah.
[AGENT][NEUTRAL] On page 8, there is a statement of patient cost.
[AGENT][NEUTRAL] From CVS Kmart.
[AGENT][NEUTRAL] OK. That one right there, we need the same document, but the period date has to be for [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It can be from [PII] because that right there, you didn't have a policy in that period.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEGATIVE] So it's just gonna deny it.
[CUSTOMER][NEUTRAL] Yeah, no, what.
[CUSTOMER][NEUTRAL] What the situation is the um
[CUSTOMER][NEUTRAL] For CVS Caremark to hold these documents uh on file.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEGATIVE] It it has a limit, right? So they won't be able to easily just provide me with um um.
[AGENT][NEUTRAL] I'm not sure.
[CUSTOMER][NEUTRAL] I mean it's pretty standard with with insurance companies, um.
[CUSTOMER][NEUTRAL] And pharmacies, and they just hold the uh information for 2 years or 3 years for in, in the records and then.
[CUSTOMER][NEGATIVE] Um, it's, it's way harder to retrieve it.
[CUSTOMER][NEUTRAL] Now the
[CUSTOMER][NEUTRAL] The drug and the prescriber and even the provider I guess of the the medication which is CVS Caremark specialty uh it's the same so I guess the statement of patient costs would just be an example of uh all the payments that were done of the submitting the payments.
[AGENT][NEUTRAL] Yeah, but we cannot use an example. We need to use the usual document.
[AGENT][NEUTRAL] I don't know if you can, we need the usual document, so it has to be.
[CUSTOMER][NEUTRAL] Do you guys need
[CUSTOMER][NEUTRAL] Yeah, I mean, I can, I, I can talk to the, to the examiner, um.
[AGENT][NEUTRAL] Oh, no, if you can.
[CUSTOMER][NEUTRAL] To see why the
[AGENT][NEUTRAL] Mmm. You need to call camera. You need to call camera and see if there's any way they can retrieve that information for you.
[CUSTOMER][NEUTRAL] Well, what will happen if uh they cannot retrieve that information?
[AGENT][NEUTRAL] Um, I'm not really sure about that because we're gonna need that document, um,
[AGENT][NEUTRAL] Again, I can go ahead and
[AGENT][NEUTRAL] What the examiner is gonna say is she's gonna have to process the claim. Once it's processed, they can talk to you. That takes 7 to 10 business days, OK? So in 7 to 10 business days, OK, in 7 to 10 business days, more than likely this is gonna be denied. You can come back and speak to an examiner. um, but
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah, we can wait.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, um, again, I'm just giving you what I see right off the back.
[AGENT][NEUTRAL] So if you have any way of getting that information, you can go ahead and do it so we can process um correctly and accordingly and we don't have to deny the claim. So, um
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah, I, yeah, I mean right now let's, it's, it's submitted and it's uploaded so let's have the examiner look at it and then if not I can talk to the examiner.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. All right. So we're just gonna go ahead and let it be like that into um its review, OK?
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] All right. Is there anything else I may help you with today?
[CUSTOMER][POSITIVE] Uh, no, I think we should be good for now.
[AGENT][NEUTRAL] OK, and I'll go ahead and make a note of our call and about this um mail number so they have it just in case, OK?
[CUSTOMER][NEUTRAL] OK, um, yeah, actually one more thing, um, in the very first claim that I submitted, uh, with you guys.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I probably signed a
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] PHI information uh disclosure authorization uh to you guys, right? Just want to double verify that you guys have the power.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And the very first one, give me just a second, I'll have to go back to the other policy.
[CUSTOMER][POSITIVE] No, no worries.
[AGENT][NEUTRAL] And uh.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] And.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] You order
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] In this research.
[AGENT][NEUTRAL] And that one.
[AGENT][NEUTRAL] have anything.
[AGENT][NEUTRAL] Mm, no, I don't see that. Um, just go ahead and fill out the claim form, the cancer claim form.
[AGENT][NEUTRAL] And upload it as well.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Yeah I can I can upload them as a preference.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yeah, because I don't see it. I went ahead and pulled the images of what you uploaded in the beginning, but I don't see the claim form.
[AGENT][NEUTRAL] Only see the documents.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. Is there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, I think we should be good.
[AGENT][POSITIVE] OK. All right. Well, you have a good afternoon and thank you for calling APL.
[CUSTOMER][NEUTRAL] Alright, well, yes, so I'm thinking.
[AGENT][POSITIVE] You're welcome. Bye bye.
[CUSTOMER][NEUTRAL] All right, bye bye.
[AGENT][NEUTRAL] Right