AccountId: 011433970860
ContactId: dac472d9-5b4f-4ec9-99a3-79b39289808d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 405549 ms
Total Talk Time (AGENT): 171938 ms
Total Talk Time (CUSTOMER): 206708 ms
Interruptions: 2
Overall Sentiment: AGENT=0.9, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/03/dac472d9-5b4f-4ec9-99a3-79b39289808d_20250403T14:59_UTC.wav
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[AGENT][POSITIVE] And thanks for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi Miss [PII], this is [PII] in the care team. I have um Miss [PII] on the phone. She is calling um from policy number 2509977.
[CUSTOMER][NEUTRAL] She is calling about claim number 3579438. She said that she keeps noticing in the online service center that she can see it and then she can't see it and then she could see it and she can't see it. She called and spoke to somebody in the past that told her that the claim was gonna be reprocessed, um, but that's what she's calling about today is she wants to know where are we in the process of processing your claim.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And looking at the remarks, it's saying it's an educational claim which doesn't tell me anything to be able to tell her.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Oh, that's an appeal.
[AGENT][NEUTRAL] That's an appeal, yeah, but you can send her on over.
[CUSTOMER][POSITIVE] Oh, OK, alright, OK, well, well, thank you for telling me that now I know. Thank you so much Miss [PII]. Alright, it's gonna be, uh, I'm a releaser now bye bye.
[AGENT][POSITIVE] OK, no problem.
[AGENT][NEUTRAL] Alright.
[AGENT][POSITIVE] Good morning. Thanks for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hi, I'm checking the status of a claim that was submitted.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, and the date of service was the [PII], is that correct?
[CUSTOMER][NEUTRAL] It's um.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, OK, uh, it looks like that claim, uh, we was treated as an appeal.
[AGENT][NEUTRAL] And let's see, it looks like that claim was processed on [PII], and so you should be receiving a letter with uh with an explanation of why the benefits were not allowed on this claim.
[CUSTOMER][NEUTRAL] OK, well, what, why aren't they allowed on the claim?
[AGENT][NEUTRAL] Uh, because the services, that actually phar pharmacy charges for a pharmacy are not covered under this policy.
[CUSTOMER][NEUTRAL] I understand, but the issue is, is that it's a drug for a knee injection. It wasn't like a prescription I was taking. It was, it was a drug that was sent straight to the physician's office and it was injected in my knee. It was for a procedure.
[AGENT][NEUTRAL] Yes ma'am, we understand and the letter is gonna the letter explains all of that information.
[CUSTOMER][NEUTRAL] So all the letter says is that it's not paid because it's a what?
[AGENT][NEUTRAL] No ma'am, the letter goes into more detail.
[CUSTOMER][NEUTRAL] I mean that
[AGENT][NEUTRAL] It goes into more detail as to why the benefits were not paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, so why wasn't it paid? Why can't you just tell me what the what it says? Why wasn't it paid?
[CUSTOMER][NEUTRAL] I, I have to, you have to give me another explanation other than it's a prescription just because it came from a pharmacy doesn't mean that it's actually a prescription. I mean, I pulled the information on the policy that clearly states that it should be paid. It's a pro it's, it's a, it's part of a procedure that was done on my knee.
[AGENT][NEUTRAL] Uh, yeah.
[AGENT][NEUTRAL] That's correct. So if the doctor, if the doctor had purchased the drug and billed for the drug himself, then it would be payable by APL but being that the drug was purchased from a pharmacy and those are the pharmacy charges.
[AGENT][NEUTRAL] The the policy does not pay for pharmaceutical drugs.
[CUSTOMER][NEGATIVE] Oh my [PII], so everything that I said makes no sense to y'all.
[AGENT][NEUTRAL] No, ma'am, I'm not saying that.
[CUSTOMER][NEUTRAL] OK, because it basically says, you know, you're, the, the things that are excluded are drugs.
[CUSTOMER][NEUTRAL] Outside of a covered facility that and it's not like I said before, this is not a prescription that was sent that was for me this prescription went straight to the doctor's office.
[AGENT][NEUTRAL] OK, but being that it was billed by the pharmacy.
[CUSTOMER][NEGATIVE] I never, this never came to this point.
[AGENT][NEUTRAL] It was billed, it was billed by the pharmacy. So the pharmacy is the one who the.
[CUSTOMER][NEUTRAL] Huh?
[AGENT][NEUTRAL] You know, if the pharmacy had not just billed you for the drug or billed whoever for the drug, uh, then we could have paid it. If the doctor had purchased the drug. So if when that drug came to us on the explanation of benefits, if it had said doctor, whatever your doctor's name was, then we could, we could have paid for that because the doctor actually purchased the drug and gave you the injection. But being that it was purchased outside from the pharmacy. So those are the pharmacy charges.
[AGENT][NEUTRAL] Uh, so we don't pay for the pharmacy charges for pharmaceutical for prescriptions.
[AGENT][NEUTRAL] And so like I stated the letter actually goes into more detail um if you don't agree, you can appeal that decision again and we can have someone else look at it a little bit more in depth.
[CUSTOMER][NEUTRAL] Yeah, I mean, I, I, I've sent you know everything that I could possibly think of to send you. I mean, the issue is that the doctors, you know, the doctor instructions were for me to, you know, purchase this and then have it sent straight to them so that they could inject it because they do not deal with purchasing drugs at their office, so that was the reason why.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I had to do the way I did. I mean this has been paid, so it's just that I just wanted to try to get that reimbursement for because like I said, it's not like it's a prescription that I was taking, you know, that came, it never came to me when it went straight there. So what would I need in order to appeal this other than what I've already sent?
[AGENT][POSITIVE] I do, I do understand. I do understand.
[CUSTOMER][NEUTRAL] I mean, is there something else that I'm gonna need? Is there some other kind of form or something else that I need to do? Do I need the doctor to sign off on something?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] No, ma'am. Once you get the letter,
[AGENT][NEUTRAL] Once you get the letter from us uh with our decision, uh, that was mailed out on [PII], you can review that and if you do not agree with that decision, you can just send us a copy of that letter and stating that you do not agree and the reasons why you do not agree and then we will, um, they'll look at it again and send it to another department for review to see if they agree with the decision that was made on this appeal.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] And then that would be the final decision. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I will try that and see what happens.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, Ms. [PII], is there anything else I can help you with today?
[CUSTOMER][POSITIVE] OK. Thank you.
[CUSTOMER][NEUTRAL] No, thank you.
[AGENT][POSITIVE] Alright have a great rest of your day bye bye.
[CUSTOMER][NEUTRAL] Bye. You too, bye.