AccountId: 011433970860
ContactId: 515736b1-83fd-4d41-98bd-3a2328faab77
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 521419 ms
Total Talk Time (AGENT): 181846 ms
Total Talk Time (CUSTOMER): 207235 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/10/515736b1-83fd-4d41-98bd-3a2328faab77_20250610T21:49_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, I had just called a second ago and I think I got disconnected. Um, I was trying to follow up on some information regarding one of my claims.
[AGENT][NEUTRAL] OK, I can verify claim status for you. And your name is?
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] OK, and the policy number?
[CUSTOMER][NEUTRAL] 02589560
[AGENT][NEUTRAL] Thank you. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] OK, thank you. And the patient's name, uh, [PII], I'm talking to you like your provider, uh, verify your date of birth, mailing address and email address, please.
[CUSTOMER][POSITIVE] You're good.
[CUSTOMER][NEUTRAL] Uh, [PII] and date of birth [PII] and then [PII].
[AGENT][NEUTRAL] OK, and you said you had a question about a claim?
[CUSTOMER][NEUTRAL] Yeah, so I called yesterday just to make sure that all my documents had been like received from not only myself but my um my doctor for my claim, whoever I talked with yesterday said that everything was received. It was basically just in the process of being reviewed.
[CUSTOMER][NEUTRAL] Um, but I just got a call from my doctor's nurse saying that someone from y'all or from [PII] had sent a medical records request today to my doctor's office, but it was regarding like range that has nothing to do with this claim. And so I was just calling to see what that was about.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, there is a pre-existing on the policy, and so they have to verify if you received any treatment or diagnosed or received any medication 12 months prior to your effective date of coverage.
[CUSTOMER][NEUTRAL] I don't know if you can uh
[AGENT][NEUTRAL] Is your effective date is [PII] of this year.
[CUSTOMER][NEUTRAL] Effective date meaning.
[AGENT][NEUTRAL] When your policy became active with our company?
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Oh, OK, um.
[CUSTOMER][NEUTRAL] And so wait what was the request for? I'm sorry, I was, I was trying to follow what you said.
[AGENT][NEUTRAL] Uh, to check for preexisting.
[AGENT][NEUTRAL] Since your policy, since there's a twelve-month pre-existing clause on the policy?
[AGENT][NEUTRAL] Pre-existing, meaning if you were diagnosed, um, received treatment, or received any medication concerning this diagnosis prior to your effective data coverage.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I think I understand. OK, so I guess I'll just get them to send over from the previous year is is that what it was requesting?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, information prior to, yes, ma'am. So from [PII], that's the period of the check for pre-existing.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And so it's just kind of looking to see if I had any other conditions or medical or medications that I was taking that would affect this claim, correct?
[AGENT][NEUTRAL] Correct, if you were diagnosed prior to the effective data coverage.
[CUSTOMER][NEUTRAL] OK, I think I'm understanding. Sorry, all of this is like foreign language to me, so, and it's been uh.
[AGENT][NEUTRAL] Oh no, no, I get it.
[CUSTOMER][NEUTRAL] But I have to try to figure all this out, um, OK, so that's the final amount is that the last information that is needed so I called yesterday and no one had mentioned this um.
[CUSTOMER][NEUTRAL] I was thinking I was done or.
[AGENT][NEUTRAL] Uh, that's what I'm showing. It looks like, um, let me check our notes.
[AGENT][NEUTRAL] Uh, looks like she requested that information today.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Well.
[AGENT][NEUTRAL] And it says latest claim received physician's claim form.
[AGENT][NEUTRAL] The policy and we need your employer's portion of the form.
[AGENT][NEUTRAL] Let's see it.
[CUSTOMER][NEGATIVE] Which portion is the employer, so I called yesterday, whoever I talked to said all of this was complete, so I'm very confused now.
[AGENT][NEUTRAL] Let me one moment to pull up the claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment I'm trying to pull up the information.
[CUSTOMER][NEUTRAL] Because all I received was this like form.
[CUSTOMER][NEUTRAL] The, like the, the claim form.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I, I was told I filled everything out statement of insured.
[CUSTOMER][NEUTRAL] Um, policy information, physicians.
[CUSTOMER][NEUTRAL] And then my statement.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] The last portion of the form, uh, the state's policyholder statement, uh, that's the information that needs to be completed by your employer.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Very confusing because no one told me that. OK. Um, so that last part needs to be filled out.
[AGENT][NEUTRAL] By your employer.
[CUSTOMER][NEUTRAL] But the policy holder, I'm the policy holder, not my employer, so I'm confused by that.
[AGENT][NEUTRAL] You're the subscriber, but they are the policy holder.
[CUSTOMER][NEUTRAL] Cause that's someone I talked to about
[CUSTOMER][NEUTRAL] OK, well, whoever I originally talked to.
[CUSTOMER][NEUTRAL] Said that that was me, OK, um.
[CUSTOMER][NEUTRAL] So I need that.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] And while I have you on the phone, what else needs to be filled out?
[AGENT][NEUTRAL] U[PII], that's all I'm showing, uh, your employer's portion and they requesting medical records.
[CUSTOMER][NEUTRAL] I've called like 5 times.
[AGENT][NEUTRAL] Oh, we do need your employers to pull out that um policyholder statement.
[CUSTOMER][NEUTRAL] Not.
[CUSTOMER][NEUTRAL] OK, that last portion and then.
[CUSTOMER][NEUTRAL] That should be everything that in the medical records.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, once I get this all sent, I, I was told it was supposed to be done by like this upcoming Monday. It does a date change now since.
[AGENT][NEUTRAL] Well,
[CUSTOMER][NEGATIVE] Apparently this is not
[AGENT][NEUTRAL] Until they receive uh the employer's portion and those medical records, um, well, if they receive the employer's portion before medical records, then it would just be pending medical records. Once the medical records have been received and we have your employer's portion of the form, uh, what will happen is then the medical records will be reviewed. After the review, then that's when they would give out the claim decision.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and how long will that take?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] As far as the review can take a while.
[AGENT][NEUTRAL] I'll say maybe 2 weeks.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Once the medical records have been received.
[CUSTOMER][POSITIVE] Oh my goodness. OK.
[CUSTOMER][NEUTRAL] OK. Well, whoever I talked to yesterday and whoever I've talked to previously has not.
[CUSTOMER][NEGATIVE] Explained any of this. I was told I was here by this that's OK, um, just frustrating.
[AGENT][POSITIVE] Oh, I'm sorry.
[AGENT][NEUTRAL] I understand.
[CUSTOMER][NEUTRAL] So all the last page of the thing for my employer and the medical records.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] And then at some point
[CUSTOMER][NEUTRAL] In theory
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK, well I will get on that and hopefully that will be the end of this.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah. Thank you.
[AGENT][POSITIVE] Alright, yes, ma'am. Thank you for calling APL. Have a great day, Ms. [PII].
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Hm.