AccountId: 011433970860
ContactId: 0b092364-fec9-4623-891a-0fe9ae276c5c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 592780 ms
Total Talk Time (AGENT): 242907 ms
Total Talk Time (CUSTOMER): 102563 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/0b092364-fec9-4623-891a-0fe9ae276c5c_20250103T18:07_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I'm so sorry my dogs are barking.
[CUSTOMER][POSITIVE] Hold on one second, I'm so sorry.
[AGENT][POSITIVE] That's OK. No worries.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][POSITIVE] I'm sorry about that.
[AGENT][POSITIVE] Mhm. No worries.
[CUSTOMER][NEUTRAL] Um, I called yesterday and I just wanna make sure the codes that I gave are are considered.
[AGENT][NEUTRAL] OK. Um, are you the insured or you are you a provider? What were the codes?
[CUSTOMER][NEUTRAL] I'm a provider.
[CUSTOMER][NEUTRAL] Um, the first one is S as in Sam 937999-60199602.
[AGENT][NEUTRAL] And so were you calling on like a patient's plan to see if that was covered or?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Do you have their policy number by chance or anything?
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][POSITIVE] Yes, I do.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It is 02576376.
[AGENT][NEUTRAL] Alright, let me pull this up here. Let me take a look.
[AGENT][NEUTRAL] OK. And then what is the patient name and date of birth?
[CUSTOMER][NEUTRAL] [PII] and it's [PII].
[AGENT][POSITIVE] All right, thank you so much. So let's see here.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, so yeah, I did see that you had called yesterday. It was about an infusion therapy.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So I can double check and see. I'm not certain that I have a way to check all the codes. I can double check for you. I know that this particular plan is a limited benefit plan, so it just pays a set amount, you know, depending upon what they're being seen for. I know yesterday they had given you the office visits and all that, which is looks like for a calendar year.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, but our services aren't done in a doctor's office they're done in an ambulatory infusion suite which is considered office setting but it's not a doctor's office.
[AGENT][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Let me pull up the policy and see if that gives me any more information here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, it's a newer policy, OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm reaching out to just to see if there's any other way for me to check the codes for you.
[AGENT][NEUTRAL] While I try and find the policy cause sometimes looking in the policy will give you, of course.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Just more of an idea of exactly what's covered here.
[CUSTOMER][NEUTRAL] I know, really.
[AGENT][NEUTRAL] Oh, so it does actually, as I bring this up, it does say um services provided on an ambulatory like basis, so don't think.
[AGENT][NEUTRAL] It's gonna be an issue. Let me see what else.
[AGENT][NEUTRAL] Yes, so I, and I don't see anything under the exclusions that would indicate, like I don't see anything that speaks of like any sort of infusion or.
[AGENT][NEUTRAL] That would
[AGENT][NEGATIVE] Lead me to believe it would not be covered at any level.
[CUSTOMER][NEUTRAL] OK, but, um, yesterday they said they will only pay $50 towards the claim.
[AGENT][NEUTRAL] So, yeah, it looks like let me go back to.
[AGENT][NEUTRAL] Yeah, so it looks like office visits, it's a $50 payment towards the visit and then they're allowed, it looks like a total of 4 in a calendar year, correct.
[CUSTOMER][NEUTRAL] OK, but what about the drugs J 2350 because that's thousands of dollars.
[CUSTOMER][NEUTRAL] So they'll only pay $50.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Let me see what the.
[AGENT][NEUTRAL] We will pay outpatient prescription drug benefit would it be to consider like a prescription drug?
[CUSTOMER][NEUTRAL] Yes, it is a prescription drug.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So the prescription must be ordered by a physician dispensed by a licensed pharmacist for the purpose, um, let's see, of this benefit prescription.
[AGENT][NEUTRAL] It cannot include experimental drugs.
[AGENT][NEUTRAL] Drugs, medicines, or insulin used or administered by a person while here she is confined in a hospital, rest home, or extended care facility.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like blood or blood plasma, immunizations are not covered, contraceptive materials, devices, and medications for infertility, except when required by law.
[AGENT][NEUTRAL] So, the outpatient prescription drug benefit.
[AGENT][NEUTRAL] It looks like shows it's $20 a day, a maximum of 15 days per calendar year per covered person.
[CUSTOMER][NEUTRAL] So they'll pay $20.
[AGENT][POSITIVE] Per day, correct.
[CUSTOMER][NEUTRAL] Up to 15 per year.
[AGENT][NEUTRAL] Up to 15 days per calendar year per covered person.
[CUSTOMER][NEUTRAL] OK, and so.
[CUSTOMER][NEUTRAL] The S 937999-601 and 99602 are available.
[AGENT][NEUTRAL] You can definitely submit the claim. I did reach out to my help desk. We don't have a way it looks like unfortunately I don't have a way to check all those codes for you to make certain that it would be covered, um, you know, we always say file the claim, of course, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But based off of the information you're providing me, yeah, I mean that's what the policy states on it as far as the benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Did you need me to check anything else for you?
[CUSTOMER][POSITIVE] Thank
[CUSTOMER][NEUTRAL] Yeah ma'am, that's it.
[AGENT][POSITIVE] OK, thanks for calling APL. I hope you have a nice day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Alright bye.