AccountId: 011433970860
ContactId: c315c28e-2928-4b22-b91c-a85ca1c82be3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1073910 ms
Total Talk Time (AGENT): 310903 ms
Total Talk Time (CUSTOMER): 347520 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=-1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/07/c315c28e-2928-4b22-b91c-a85ca1c82be3_20250307T20:08_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is. How may I assist you?
[CUSTOMER][NEUTRAL] Hey, I had just a couple questions about some claims that I've had recently, um, that aren't getting covered.
[AGENT][POSITIVE] OK, sure, I can assist you with claims. May I have your name and a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] My name and what else?
[AGENT][NEUTRAL] Callback number?
[CUSTOMER][NEUTRAL] Oh, my name is [PII] and my callback number is [PII].
[AGENT][NEUTRAL] OK, thank you. Do you have the policy number?
[AGENT][NEUTRAL] Is it?
[CUSTOMER][NEUTRAL] I don't have it on me.
[CUSTOMER][NEUTRAL] Hold on let me see if I have my card.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The card, let's see
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Policy number is 025.
[CUSTOMER][NEUTRAL] 39176
[AGENT][NEUTRAL] OK, and may I have your date of birth, mailing address and email address on file?
[CUSTOMER][NEUTRAL] Mhm. My date of birth is [PII]. Uh, my mailing address is [PII] and my email is [PII].
[AGENT][NEUTRAL] OK, perfect, thank you. OK, let me look at the claims, one moment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I see there's one pending for this policy um that was sent out yesterday.
[AGENT][NEUTRAL] And then the last one I see is the one that we process and pay on [PII] which she was paid directly to the provider of service.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, well, um,
[CUSTOMER][NEUTRAL] Well, I have 2 medications that I take and you, I know y'all have like a list. They sent me like the list of the 15 pages of medicines that y'all cover or whatever, but both of, like one of them is a cream that I've been from a dermatologist.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] That I've been using since [PII] and it's not covered. Uh, I just don't understand. And then another one is I take like acyclovir, the antiviral medicine, and it's not covered.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I was kinda asking like, I guess.
[CUSTOMER][NEGATIVE] I just don't understand how those are like covered. Like, who decides what medicines go on your list of things that you do covered? How can I get more coverage because this is supposed to be the most coverage that's offered to me.
[AGENT][NEGATIVE] Yeah, Ms. [PII], um, you're calling the wrong place for the pharmaceuticals. We don't have no pharmaceuticals here.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, well let me ask you another question then.
[AGENT][NEUTRAL] Mhm. Yeah. OK.
[CUSTOMER][NEGATIVE] I went to an American family care, like after work one day for like a urinary tract infection, and they said that they don't accept your insurance. And so I just had to pay out of pocket. How do I know like which provider I can go to that will be covered by y'all?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, you can always go to [PII] and put your zip code and just choose from there or um if you pay out of pocket, you can always send us a claim.
[AGENT][NEUTRAL] Aim for reimbursement based on the benefits of the policy.
[CUSTOMER][NEUTRAL] So can I send like where I paid out of pocket to see the nurse practitioner? Would y'all, could y'all reimburse that?
[AGENT][NEUTRAL] Was it like an urgent care?
[CUSTOMER][NEUTRAL] Huh?
[AGENT][NEUTRAL] Was it an urgent care or was it an office, a clinic? What type of service?
[CUSTOMER][NEUTRAL] Yeah, it was like a, it was an urgent care and I just saw like a nurse practitioner.
[AGENT][NEUTRAL] Mm, OK. You can send us a claim. Let us look into it because you do have urgent care benefits, um, and this is not a guarantee of payment, just a verification of coverage, but you do have an urgent care benefit of 150 up to 4 business per year. So let us look into it and see if it's something payable, um, so you did not see a doctor, you saw the, um, nurse practitioner?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, just the nurse practitioner.
[AGENT][NEUTRAL] Yeah, I.
[CUSTOMER][NEGATIVE] Would that not be, I mean, that should be covered, right? I gave them uh like um card and everything when I was at the like check-in and she was like, oh we don't like cover this insurance doesn't cover, uh, like she was like, we're not, they don't like, I don't know. So I just paid out of pocket. But if I, is there a way for me to send that in and get reimbursed 150 bucks?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] I cannot guarantee that over the phone, but you can submit the claim. Let us look into the documents and see if it's something payable under your policy. So you can always submit a claim and let us look into it. Um, what you're gonna need is a claim form. Um, the claim form you can find it on our website at [PII].
[AGENT][NEUTRAL] And together with that, we need the itemized bill with the diagnosis code and procedure codes so we can um determine if it's payable.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So that's gonna be hard because then I'm gonna have to get the doctor's probably gonna have to fill that out. Like that's not gonna be on my discharge paperwork.
[AGENT][NEUTRAL] Um, no, uh oh, no, it's not a form that they need to fill out.
[CUSTOMER][NEUTRAL] Postcodes should be on my cards?
[AGENT][NEUTRAL] It should be on the discharge. Um, sometimes it is, uh, all places are different, all companies or or um health providers that they work different. They all have different systems. So I'm not really sure if it's gonna have all the information on that paperwork that you receive on the discharge, but if it doesn't have it, you can always call and have them to send you an itemized bill to see if you can pick it up, um, so you can go ahead and submit your own claim.
[AGENT][NEUTRAL] But the claim form is something that you're gonna fill out it's a personal claim form.
[CUSTOMER][NEUTRAL] OK, and I just have to, OK, is there any way you could email me to, to that paper so I can fill it out?
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Do you mind holding for me while I send this out to you right now?
[CUSTOMER][NEUTRAL] Yeah, that's fine.
[AGENT][NEUTRAL] OK, thank you, one moment.
[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. OK, I went ahead and send that over to you. It should be there in a few minutes. Um, do you wanna check and see if you got it or you're gonna check later on.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, yeah, it should pop up if I get it. Um, and where do I like?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Where would I send this to? Does it have instructions for where for me to email it or send it back or whatever? It does, OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, it cannot, yeah, it cannot be emailed. It's either faxed, mail, or uploaded into the website if you register, um, but the information is in the first page, OK?
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] And it's, it should, my coverage for, I know I can look up the providers or whatever, but if I just went to an urgent care and there's a nurse practitioner there, is there, um.
[CUSTOMER][NEUTRAL] Like a reason it wouldn't be covered or something?
[AGENT][NEUTRAL] Sometimes when it's, it's, it's not a licensed doctor, it will not cover. It really depends. Um, that's why we cannot give any guarantees over the phone or we cannot process over the phone because we need to be looking at the paperwork. Mhm. Yeah.
[CUSTOMER][NEUTRAL] I got you I got you, but if it, um, like you're not saying like provider, you're saying not talking about like the difference between like an MD and a nurse practitioner, right, right?
[AGENT][NEUTRAL] Uh, kind of, yes, because a licensed doctor is different than a nurse practitioner. Now, there's sometimes that the nurse practitioner use the, the, um, MD or the doctor's authorization and that will be different, but that's gonna be in the paperwork.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I'm just, I mean, I'm just trying to like, I don't know, I don't understand why like when she looked it up, she just said like the it's not, I don't know. I don't understand how why it would do that.
[AGENT][NEUTRAL] They probably don't have a, they probably don't have a system to put uh this type of um policy or they, they just don't add any more to their system or there, there could be any uh any any reasons um there's a lot of companies that they, they just don't know and they don't know how to put it in or uh they only work with PPOs or they only work with HMOs and there there's gonna be any kind of reason, so yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] Could be a lot of reasons, OK, and then let me tell you this if we're not, uh, when I upload this and to y'all or whatever, how long?
[AGENT][NEUTRAL] Yeah, I could be.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, like, oh, something back.
[AGENT][NEUTRAL] The processing time is 7 to 10 business days.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEGATIVE] All right. Um, and then with the medicines, I think I talked to somebody about the medicines yesterday. She kinda like was like, oh, I'm sorry, I know this is frustrating, but I, I mean, I guess that's not your wheelhouse, but I mean, I just have had like basically no coverage. I feel like for.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I mean, I got covered. I went to the ER one time and that was covered, but I mean, it just feels like everything else, everything the doctors prescribed it, it's like no, and, you know, I go to the American Family Care. It was just very frustrating.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah, I understand. But yeah, if you wanna talk about your pharmaceutical, um, you can go ahead and call Pharmaal. I can give you their number. They're the ones that can help you with that, and I'm sure they're the ones that send you that information in the first place, but um let me go ahead and give you their number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let me know when you're ready.
[CUSTOMER][POSITIVE] All right, I'm ready.
[AGENT][NEUTRAL] OK, that number is 1800.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 933.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 373 [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, is there anything else I may help you with today? Do you need me to transfer you or any other thing?
[CUSTOMER][POSITIVE] Um, if you could take for me, that'd be great.
[AGENT][POSITIVE] I can. Alright, well thank you for calling APL. You have a good afternoon and one moment while I transfer, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Thank you for calling the pharmacy and member help desk. This call may be monitored or recorded for quality and training purposes. If this is a medical emergency, please dial [PII]. Please listen closely, as our menu options have changed. Para espanol numerocinco. If you are a member, please press 1. If you are calling from a pharmacy, please press 2. If you are calling for a prior authorization or from a prescriber's office, please press 3. If you are a broker, employer, or client, please press 4.
[CUSTOMER][NEUTRAL] Please stay on the line while your call is transferred to the operator.
[CUSTOMER][NEUTRAL] This call may be monitored or recorded for quality assurance purposes.
[CUSTOMER][NEUTRAL] You are caller number 2 in the queue. Please hold.
[CUSTOMER][NEUTRAL] Your call is very important to us. Please hold for the next available agent.
[CUSTOMER][NEUTRAL] You are caller number 2 in the queue. Please hold.
[CUSTOMER][NEUTRAL] Your call is very important to us. Please hold for the next available agent.
[CUSTOMER][NEUTRAL] You are caller number 2 in the queue. Please hold.
[CUSTOMER][NEUTRAL] You are caller number 2 in the queue. Please hold.
[CUSTOMER][NEUTRAL] Your call is very important to us. Please hold for the next available agent.