AccountId: 011433970860
ContactId: 04f02abc-0fae-4620-a082-463da2001c93
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 676289 ms
Total Talk Time (AGENT): 230484 ms
Total Talk Time (CUSTOMER): 263105 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/22/04f02abc-0fae-4620-a082-463da2001c93_20250122T21:06_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from Jansen sponsor Patient support program on behalf of provider [PII] to verify insurance benefits to the patient. Before we begin, I need to inform you that this call is being recorded for quality assurance and training purposes. Are you OK with it?
[AGENT][NEUTRAL] Yeah, yes, sir.
[AGENT][NEUTRAL] OK and then what.
[CUSTOMER][NEUTRAL] OK. And can you please spell your name?
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] OK. [PII], and may I know your first letter to your last name, please?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] OK, great, thanks for that.
[AGENT][NEUTRAL] OK, and now can you spell your name for me?
[CUSTOMER][NEUTRAL] Yes, of course. And my name is [PII]. It's spelled as [PII] [PII], [PII].
[AGENT][POSITIVE] OK, [PII], thank you so much and then what is your callback number, sir?
[CUSTOMER][NEUTRAL] Yes, and the callback number is [PII]. And it's a direct line.
[AGENT][NEUTRAL] Thank you, sir. And then what is the patient's name?
[AGENT][NEUTRAL] Hello?
[AGENT][NEUTRAL] No what?
[AGENT][NEUTRAL] What is the patient's name?
[CUSTOMER][NEUTRAL] Yeah, can you, do you need to spell that?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And providers, member's name is [PII]. Do you need to spell the name?
[AGENT][NEUTRAL] No, I've got it. And then what is [PII]'s, uh, date of birth?
[CUSTOMER][NEUTRAL] And date of birth is.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And patients policy number?
[CUSTOMER][NEUTRAL] And the policy number is 02272802 M as in Mary, L as in Lima, B as in Bravo.
[AGENT][NEUTRAL] OK, let me look up the policy real quick.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I do see [PII]'s um policy and her policy is is active effective [PII].
[AGENT][NEUTRAL] It is still active and this is just to verify her coverage. It's not a guarantee of payment. She has a supplemental insurance policy that is billed secondary to the primary. The policy has with deductible, co-pay and co-insurance only, and she has an inpatient benefit amount of.
[AGENT][NEUTRAL] $8200 per calendar year.
[AGENT][NEUTRAL] To go towards the deductible co-pay or co-insurance and then she also.
[AGENT][NEUTRAL] an outpatient calendar year benefit amount of $4000 to go towards the deductible co-pay or co-insurance.
[CUSTOMER][NEUTRAL] OK. So, may I know the plan name?
[AGENT][NEUTRAL] Medlink
[CUSTOMER][NEUTRAL] Medlink. OK, thanks for that. And may I know the type but it's uh
[CUSTOMER][NEUTRAL] PPO plan, HMO plan, something like that?
[AGENT][NEUTRAL] No sir, it's a it's a individual.
[AGENT][NEUTRAL] Gap insurance policy.
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] OK. Well it's a commercial plan?
[AGENT][NEUTRAL] I'm sorry, what did you say, sir?
[CUSTOMER][NEUTRAL] Whether it's a commercial plan or government plan?
[AGENT][NEUTRAL] In the American public life plan.
[CUSTOMER][NEUTRAL] OK. American. OK. Just one moment.
[CUSTOMER][NEUTRAL] So the provider is in-network with you.
[AGENT][NEUTRAL] There's no network.
[CUSTOMER][NEUTRAL] OK. And may I know whether you are the commercial one or government plan?
[AGENT][NEUTRAL] It's an enrollment plan that's done through her group employer.
[CUSTOMER][NEUTRAL] OK. And the plant type is American?
[AGENT][NEUTRAL] The plan type is Medlink.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And you are the secondary insurance, I'm I right?
[AGENT][NEUTRAL] Right, this is secondary.
[CUSTOMER][NEUTRAL] OK, whether it's a self-funded plan or fully insured plan?
[AGENT][NEUTRAL] I'm sorry, what? I'm sorry, I didn't understand the question.
[CUSTOMER][NEUTRAL] Whether it's a self-funded plan or fully insured plan.
[AGENT][NEUTRAL] It's self funded through her employer.
[CUSTOMER][NEUTRAL] OK. And may I know the group number?
[AGENT][NEUTRAL] The group number is 22449.
[CUSTOMER][NEUTRAL] 224
[AGENT][NEUTRAL] 22449.
[CUSTOMER][NEUTRAL] OK, thanks for that. And let's move on to medical benefits. Is there any individual deductable for this member?
[AGENT][NEUTRAL] Do I have what for the member?
[CUSTOMER][NEUTRAL] Is there any individual deductible for this member?
[AGENT][NEUTRAL] Uh, no, sir. This plan helps with deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] So there is no co-pay, deductible co-insurance, am I right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So the plan covers 100% each. OK, thanks for that.
[CUSTOMER][NEUTRAL] And is there any lifetime maximum benefit cap?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Whether the provider can buy and build the truck.
[AGENT][NEUTRAL] The provider can do what, sir?
[CUSTOMER][NEUTRAL] Whether the provider can buy and build the truck?
[AGENT][NEUTRAL] Yes, the provider can bill direct would you like the payer ID number?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yes, may I know the pharmacy name?
[AGENT][NEUTRAL] We don't have a pharmacy.
[CUSTOMER][NEUTRAL] No, so you said the provider can buy and build the drug. And is there any specialty pharmacy the provider can buy and bill?
[AGENT][NEUTRAL] No, this is a supplemental medical policy that helps with deductible co-pay or co-insurance. So it's billed secondary to the primary. So when they go to the doctor, they need to give their primary insurance card and this one too.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So the
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so the provider must buy in bulk. And is there any referral list ticket for this plan or not?
[AGENT][NEUTRAL] Is there what for the plan?
[CUSTOMER][NEUTRAL] Is there any PCP referral list like for this plan?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK. And whether prior authorization is taken for the drug?
[AGENT][NEUTRAL] No, there's no prior authorization.
[CUSTOMER][NEUTRAL] OK. And this, whether a step therapy is for this plan?
[AGENT][NEUTRAL] What would be what for the plan?
[CUSTOMER][NEUTRAL] Whether a step therapy is record for this drug.
[AGENT][NEUTRAL] There's no drugs, it's deductible co-pay or co-insurance.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK. Whether a predetermination is required or not.
[AGENT][NEUTRAL] There's no predetermination.
[CUSTOMER][NEUTRAL] OK. Is there any separate prior authorization department or you're the only one handling the prior authorization to?
[AGENT][NEUTRAL] Um, there's no prior authorization.
[CUSTOMER][NEUTRAL] OK. OK, right, thanks for that. And try and for a quick recap. You are showing the secondary insurance and the effective date is [PII]. The plan is still active and plan name is Medli and the plan type is commercial Medli and it's a self-funded plan. And the group number is 22449 and there is no individual and the family deductable. There is no individual or the family out of pocket maximum. There is no co-pay and co-insurance. The plan covers 100%.
[CUSTOMER][NEUTRAL] And there is no lifetime maximum benefit gap. The provider must buy and build the drug and there is referral is not required, prior authorization is not required, pre-determination is not required, the therapy also not required. And there is no separate prior authorization department. Am I right, [PII]?
[AGENT][NEUTRAL] True, but I never said it paid 100%.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is there any patients responsibility like deductible, out of pocket, maximum, co-pay and co-insurance?
[AGENT][NEUTRAL] No, this policy helps with deductible, co-pay, and co-insurance.
[CUSTOMER][NEUTRAL] OK, whether the member has a deductible out of pocket max some something like that or not?
[AGENT][NEUTRAL] It depends it depends on what the primary insurance pays.
[AGENT][NEUTRAL] Once the primary insurance EOB is sent to us with what, with their paying their part, then that determines on what this policy will pay.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Oh, OK. For, for this policy, there is no deductible out of pocket, co-pay and coin insurance, you, you pay the remaining of the primary one, am I right?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sorry, can you please repeat that once again?
[AGENT][NEUTRAL] No, if the primary insurance does not cover the procedure, then we don't cover it either.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And you
[CUSTOMER][NEUTRAL] And you pay the remaining leftovers of the primary one, am I right or not?
[AGENT][NEUTRAL] No, it depends on what the procedure codes are on the explanation of benefits from the primary.
[CUSTOMER][NEUTRAL] OK. Can you please check the benefits for the procedure goods?
[AGENT][NEUTRAL] No, there's no procedure codes that we have. We only cover deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] OK. And for this member for under this plan, is there any deductible or out of pocket maximum co-pay or coinsurance? There is no some deductable out of pocket maximum co-pay coinsurance.
[AGENT][NEGATIVE] Uh, no, I've already, no, I've already answered that 3 times, no.
[CUSTOMER][NEUTRAL] OK. And you cross over with the primary one, am I right?
[AGENT][NEUTRAL] Correct, primary is billed first, and we are billed secondary.
[CUSTOMER][NEUTRAL] OK, [PII]. Thanks for that. And [PII], may I know the call reference number for this call?
[AGENT][NEUTRAL] Yes, you can use my name.
[AGENT][NEUTRAL] And today's date.
[CUSTOMER][POSITIVE] OK, great. Thanks for the details and given to me. Have a nice day and bye for now.
[AGENT][POSITIVE] You, you too. You have a blessed day, [PII]. Thank you for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Bye. Bye.