AccountId: 011433970860
ContactId: fd96c2c9-6153-41dd-839f-4b62644bc3c1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1137839 ms
Total Talk Time (AGENT): 390500 ms
Total Talk Time (CUSTOMER): 194934 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/24/fd96c2c9-6153-41dd-839f-4b62644bc3c1_20250224T18:30_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling A. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] over on the care team. How are you?
[AGENT][NEUTRAL] I'm doing OK yourself?
[CUSTOMER][NEUTRAL] Doing all right, thank you. Um, I've got a member on the line, uh, calling regarding a claim they submitted under their cancer policy. Um, long story short, I guess there was no pathology report. The diagnosis of cancer came from an MRI and that claim was denied as needing the pathology report. Um, I see a note where she'd called and spoken with us before regarding it, but I don't know that there's been any update or if she should just appeal this. If you wouldn't mind taking a look at it for me.
[AGENT][NEUTRAL] OK, what's the policy number?
[CUSTOMER][NEUTRAL] It is 112479.
[CUSTOMER][NEUTRAL] And it is for uh part one.
[AGENT][NEUTRAL] A callback number?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] OK, you can go on to another.
[CUSTOMER][NEUTRAL] OK, so we're speaking with um [PII], she's the daughter um and she has power of attorney.
[AGENT][NEUTRAL] OK, that's fine.
[CUSTOMER][POSITIVE] OK, thank you. Bye bye.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Good afternoon. Thanks for calling APL. It's [PII]. Am I speaking with [PII]?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK, the repstairs you have a question, um.
[AGENT][NEUTRAL] Uh, about a claim for your, let me see, for your mother.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. Um, give me one second. Let me go ahead and take a look at the notes and the claim, and I'll be right back with you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, can I put you on a brief hold, please?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mm, I know it was something I forgot to do.
[AGENT][NEUTRAL] Uh.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Background on some common global policy and home let me see what.
[AGENT][POSITIVE] I like that.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Uh,
[AGENT][NEGATIVE] Strabo.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, [PII], thanks for holding. So, um,
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] I was going through the notes um where you had a call, I guess about a week ago, um, in regards to the claim, um, not having um a path report and trying to
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Find out from my supervisor in regards to this because they were taking a look at it, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm trying to see, hold on one second, and I'm trying to look to see what she, her response was, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Cause you were saying the, the cancer came from an MRI and there was no, they didn't um do a um a pass.
[CUSTOMER][NEUTRAL] They were unable to do a biopsy, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] OK, do you have any um bills or explanation of benefits, um, from the, what he's had done, um, so far, is it, or just only?
[AGENT][NEUTRAL] Um, because right now what we have, the only thing that can be paid based on what we have is, um, let me see.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, so, um, the only thing that can be done right now, um, until you send in an explanation of benefits, um, I can reprocess the claim and for the MRI and process it under because the policy has a positive diagnostic test benefit, but I would be denied it needing the EOB um for claim consideration.
[CUSTOMER][NEUTRAL] Let me ask you
[CUSTOMER][NEUTRAL] I, I spoke with someone, I don't know, I guess whenever it was a week or two ago, um, asking if she has incredible insurance, not this one, but incredible health insurance, that's, I mean, that's all paid for. Our biggest expense was her long term care because she needed 24 hour care for 3 full months.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And she looked something up. The first person told me no, this policy that she's been paying for for literally decades would not cover any of that. And then the person I spoke with last said yes, it would, but they were unsure of why still the MRI was not being accepted, since they couldn't do a biopsy.
[AGENT][NEUTRAL] So, um, let me go, so let me go to this because I'm the one that processed the original claim and so when my, when the claim, let me go to the actual, hold on one second.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So the claim was sent to audit, um, and so when it was sent to audit, um, I did a line requesting a path report because that's what I was supposed to do and then um there's a line for non-cover for MRI. So on the policy, it doesn't cover for um for.
[AGENT][NEUTRAL] Any testing. So when it came back, it was reviewed um by my supervisor and the only thing that she said that can be done is process an MRI under. There's a benefit on the policy called the lab and.
[AGENT][NEUTRAL] Testing benefit um if there's a positive diagnosis. But, um, I said, even at that, um, that would have to be processed, but we would have to request the EOB. So if you send her the insurance, the primary insurance paid for all of the MRI and there's no um out of pocket, then
[AGENT][NEUTRAL] There wouldn't be anything paid. But as far as the long term care.
[CUSTOMER][NEUTRAL] So, so long-term care was not covered in her policy, is that what you're saying?
[AGENT][NEUTRAL] Well, I'm, well, I was getting to that, but I'm, what I was saying is that I'm gonna look up the policy to see if I see anything about long-term care. Um, I was explaining the first part, um, so give me one second.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right. I, I, I understand that.
[AGENT][NEUTRAL] Give me 1 2nd.
[AGENT][NEUTRAL] Just.
[AGENT][NEUTRAL] The long term care was for, because of the cancer, correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it's um she's actually in a facility or they come in like to the home um for care?
[CUSTOMER][NEUTRAL] No, she was at home. Yeah, they came to her home.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. So, it would possibly fall up under, there's a benefit on here called a home nursing benefit, um, and what this benefit says, it says we will pay this benefit if you require the full-time services of a nurse while confined at your home. Um, and it says we'll pay the extra charges for services not to exceed $100 per day.
[AGENT][NEUTRAL] Um, and it just says the services have to, must be ordered by the attending physician. And, um, it only says services must be.
[CUSTOMER][NEUTRAL] She was on, she was on hospice. It was not a nurse, it was just a caregiver and she was on hospice.
[CUSTOMER][NEUTRAL] And we used a caregiver service 24/7, so I'm assuming that's not covered.
[AGENT][NEUTRAL] So let me look at, um, that's the one that has to do with if she's at home, let me see if there's another one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] She was at home on hospice.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Paying if you can.
[AGENT][NEUTRAL] OK. So there's a hospice care benefit, um, but I can tell you what it says, but I mean, you would, it would probably be best to go ahead and send in the um bills and the um explanation of benefits for it so that way we can see how it's being billed, um, because it might fall up under this hospice care benefit and it just says, hold on one second, let me see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, because it says we'll pay the benefit if you receive care provided by a hospice as a result of cancer.
[AGENT][NEUTRAL] Um, it just says we'll pay actual charges.
[CUSTOMER][POSITIVE] But I didn't have to pay for her hospice, her health insurance paid for hospice we paid out of pocket for the caregivers through an agency.
[AGENT][NEUTRAL] OK, so, um,
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] So as far as a caregiver, was that submitted through insurance or you just pay out of pocket for that?
[CUSTOMER][NEGATIVE] No, it was out of pocket.
[AGENT][NEUTRAL] OK, so in that case, we wouldn't pick it up because, um, so this benefit only pays, um, we pay actual charges and that's something that um that's based on the explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] OK, who do I need to speak with to cancel this policy?
[AGENT][NEUTRAL] So let me see.
[AGENT][NEUTRAL] I believe you would send a letter in, but I'm just trying to verify that for you before um.
[AGENT][NEUTRAL] Before that, hold on one second.
[AGENT][NEUTRAL] Excuse me.
[AGENT][POSITIVE] I'm sorry to keep you waiting. I'm just trying to get you the right answer.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, um, so what I can do, I can get you over to our customer service department, um, and they will let you know the steps that you can do, um, to get the policy canceled, um, and I can let them, um, I can give them your information. Give me one second.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Referring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[AGENT][NEUTRAL] Hi [PII], this is [PII] in the claims department. How are you doing?
[CUSTOMER][NEUTRAL] I'm fine, Ms. [PII]. How are you there?
[AGENT][POSITIVE] I'm doing OK.
[AGENT][NEUTRAL] Um, so I have, um,
[AGENT][NEUTRAL] A POA wanting to um cancel the policy for
[AGENT][NEUTRAL] Their parents, well, the mother.
[CUSTOMER][NEUTRAL] OK, what's that policy number, dear?
[AGENT][NEUTRAL] 112479.
[CUSTOMER][POSITIVE] Yeah, let's see, hopefully they're listed.
[AGENT][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] So she has listed a goody goody goody.
[CUSTOMER][NEGATIVE] Sorry for my lack of enthusiasm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, so [PII] and, and [PII] are the
[CUSTOMER][NEUTRAL] Legal legal power of it. OK. OK. All right, put Mr. [PII] also, did you verify anything?
[AGENT][NEUTRAL] Yeah, so it was transferred to me from the care team now.
[CUSTOMER][NEUTRAL] OK, so they verified it. I get it.
[AGENT][POSITIVE] Yes, um, I can give you the callback number if you want that.
[CUSTOMER][NEUTRAL] [PII]. I just copied it hopefully I won't copy something else over it, but I got it.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] Thank you, dear.
[AGENT][NEUTRAL] Uh-huh.