AccountId: 011433970860
ContactId: 126dfd28-f448-4e22-9fe2-7f0a28b28944
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 925979 ms
Total Talk Time (AGENT): 314456 ms
Total Talk Time (CUSTOMER): 455740 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/02/126dfd28-f448-4e22-9fe2-7f0a28b28944_20250402T19:59_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII], and I'm on a recorded line and I'm calling to verify benefits for a patient who's coming into the office for infusion therapy, and I need to verify coverage for specific procedure codes. Did you say your name was [PII]?
[AGENT][NEUTRAL] OK, and
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And what's the policy number [PII]?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Policy number is 01792121.
[AGENT][NEUTRAL] OK, and what's a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] My direct line is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII], uh, [PII].
[AGENT][NEUTRAL] OK, thank you. And we're checking eligibility and then treatment in the office setting?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. So I'm showing an effective date.
[CUSTOMER][NEUTRAL] Yes, it's gonna be done in our specialist.
[AGENT][NEUTRAL] Uh-huh OK, office, OK.
[CUSTOMER][NEUTRAL] Oh, sorry.
[AGENT][NEUTRAL] The policy effective date is [PII].
[AGENT][NEUTRAL] Uh, the policy is active at this time.
[AGENT][NEUTRAL] And you said it's for infusion therapy?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And, and it's
[CUSTOMER][NEUTRAL] And then do you take procedure codes or is it just description based?
[AGENT][NEUTRAL] You can give it to me if you like.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Um, it's, the first one's for the medication to expire, and it's J2356.
[CUSTOMER][NEUTRAL] The admin code is 96365 with the diagnosis code of J like Juliet 45.51.
[CUSTOMER][NEUTRAL] And then just to let you know this is not related to cancer, um, and yeah, it's gonna take place in the specialist office, place of service 11, but there's not gonna be an office with the bill.
[AGENT][NEUTRAL] You said J 45.51?
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Of course we can't uh guarantee benefits. We can only provide you what the benefit policy is for this patient, and that is up to $5000.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um, per calendar year.
[AGENT][NEUTRAL] And the inpatient and outpatient benefit is combined, a combined maximum of up to $5000 per calendar year, um.
[AGENT][NEUTRAL] So it is infusion therapy. The claim can be submitted for review KC, but I can't again guarantee payment of the claim until after we get the itemized bill and the major medical EOB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so is the $5000 like an out of pocket?
[AGENT][NEUTRAL] That's the benefit, um, it covers up to 5000 per calendar year, so, um, the amounts, the, uh, major medical carrier carrier applies towards deductible, co-insurance, and or co-pay.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Um, are the amounts that we, um.
[AGENT][NEUTRAL] We'll review for covered charges and the benefit is up to 5000 per calendar year.
[CUSTOMER][NEUTRAL] OK, so you cover, so this is secondary, right?
[AGENT][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] And then, so you'll pick up, you'll cover deductibles, co-insurance and um up until $5000.
[AGENT][NEUTRAL] Mhm of covered charges, that is correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so is that like the Benefit max?
[AGENT][NEUTRAL] 5000. Mhm.
[CUSTOMER][NEUTRAL] 5000. OK.
[CUSTOMER][NEUTRAL] Up to $5000.
[CUSTOMER][NEUTRAL] OK, have they met anything or used any of that yet?
[AGENT][NEUTRAL] I'm showing
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Of the outpatient and inpatient combined right now we've only paid out $13.70 for 2025.
[AGENT][NEUTRAL] You're 2025.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] $13.70.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Um, and then once they, once you pay that, you then they're no longer covered or that you don't pay anymore, right?
[CUSTOMER][NEUTRAL] Like they no longer have.
[AGENT][NEUTRAL] Once to 5000 is met.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Yeah, because that's the maximum for the calendar year, so we pay out that amount, any claims after that will be denied his benefit is exhausted.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Ma.
[CUSTOMER][NEUTRAL] OK, so there's no deductible, no co-insurance, uh, no copays. They only have the $5000 benefit max, and so you will pick up like the deductibles and co-insurance from the primary insurance and then once they reach the $5000 then the, the benefit is exhausted.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] For the calendar year.
[CUSTOMER][NEUTRAL] Yeah I understand that right? OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For the calendar year.
[CUSTOMER][NEUTRAL] So this plan runs on a calendar year then.
[AGENT][NEUTRAL] And the
[AGENT][NEUTRAL] And the inpatient and outpatient benefit is combined.
[AGENT][NEUTRAL] So it's 5000 between the two.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So no matter where, if it's an inpatient service or an outpatient service, they're combined.
[AGENT][NEUTRAL] You know, the accumulation is is together, so if they have inpatient services and we pay 5000, the outpatient benefit is max because they're combined.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] The benefit is combined.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and then, can we buy and bill on this, uh, um, under the medical benefit? Buy and bill the drug?
[AGENT][NEUTRAL] No
[AGENT][NEUTRAL] No. No.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we would um we're required to obtain the drug through a specialty pharmacy because the drugs not covered.
[AGENT][NEUTRAL] I mean we cannot advise.
[CUSTOMER][NEUTRAL] Huh.
[AGENT][NEUTRAL] We can't advise you with any information.
[CUSTOMER][NEUTRAL] OK, so you're just saying you can't, we can't um use the drug we have in office and then bill it under the medical benefit under this plan, right?
[AGENT][NEUTRAL] Is that the J code? Is that the J code?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK, yeah, go ahead and send that claim in for review again. We can't guarantee anything until we get that actual document, but that's a J code, so that's an injection, isn't it?
[CUSTOMER][NEUTRAL] Yes, it, um, injection infusion, are there, is it different for versus injection versus infusion?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Let's see, give me 1 2nd.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, that's, that's 22 different procedures.
[AGENT][NEUTRAL] They're not the same.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I know I'm just wondering if it's a different if the benefits are different um from injection versus infusion.
[AGENT][NEUTRAL] Yeah, so it's outpatient, so the outpatient benefit is up to 5000. It's still 5000.
[CUSTOMER][NEGATIVE] I mean it's gonna be infused, it's gonna be infused.
[AGENT][NEUTRAL] Per calendar year, the benefit is the same.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, but we can't buy and build the drug and
[AGENT][POSITIVE] Correct. Correct.
[CUSTOMER][NEUTRAL] Um, but it's still covered under, I mean,
[CUSTOMER][NEUTRAL] So the drug's not covered under this plan or it is?
[AGENT][NEUTRAL] You know, so, so the J code.
[AGENT][NEUTRAL] Are you just administering? Yeah, the J code. It's an injection?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And again I can't guarantee anything, [PII], so we're kind of going around in circles.
[CUSTOMER][NEUTRAL] Right, I understand that. No, I understand that. I, I mean, I, I know you can't guarantee it. I'm just, I'm just wondering because, um, you know, typically we would, we wanna buy and build a drug. And so I'm just trying to understand how this plan works. So, um, if the drug would be covered under medical or you're just a secondary, you'll pick up whatever the primary doesn't cover up until $5000.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, not what they don't cut, well, whatever they apply towards deductible, co-insurance, and or co-pay amounts.
[CUSTOMER][NEUTRAL] Because I know we already established that.
[CUSTOMER][NEUTRAL] OK. So, right.
[AGENT][NEUTRAL] It's what we will review.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, is there, is there like a carveout list on this plan? um.
[AGENT][NEUTRAL] No, there isn't.
[CUSTOMER][NEUTRAL] Of
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and then do you have a, a preferred specialty pharmacy or?
[AGENT][NEUTRAL] No, because we're we're following the major medical. This is the gap plan.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] So there's no prescription.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, benefits under this policy.
[CUSTOMER][NEUTRAL] OK, so you follow the primary plan.
[CUSTOMER][NEUTRAL] Is that right?
[AGENT][NEUTRAL] Yes, well, our, our payment amount is based on the primary's explanation of benefits. We don't follow their plan, but our payment is based on the ELB from the major of the the major medical ELB.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Something else for you.
[CUSTOMER][NEUTRAL] OK, um, and did you say prior authorization is required?
[AGENT][NEUTRAL] I did not, but it's not required.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] It's not required.
[CUSTOMER][NEUTRAL] So prior authorization is not required and so you probably you probably don't have any authorizations on file.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] An authorization is not required.
[CUSTOMER][NEUTRAL] Right, is the predetermination recommended at all or optional and reviewable?
[AGENT][NEUTRAL] Not under this policy, you would just submit your CMS 1500 form and the major medical EOB for review.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so, um, this plan runs on a calendar year and is it fully funded then?
[AGENT][NEUTRAL] Well, it's a, it's a gap policy.
[AGENT][NEUTRAL] So it's not fully funded?
[CUSTOMER][NEUTRAL] And it
[CUSTOMER][NEUTRAL] OK, is the PCP referral required?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] It is not.
[AGENT][NEUTRAL] Because it's a gap policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and then next I would just need a good claims address.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Which is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK awesome and then do you have a payer ID at all?
[AGENT][NEUTRAL] It's 60801.
[CUSTOMER][POSITIVE] OK perfect thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] I think um that's all I needed. So, for the benefits, you will cover um the deductible, co-insurance, or co-pay.
[CUSTOMER][NEUTRAL] Um, up until the $5000 benefit max for the calendar year.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And the inpatient and outpatient benefit is combined.
[CUSTOMER][NEUTRAL] The Benefit max is $5000. They've used $13.70.
[CUSTOMER][NEUTRAL] Um, we cannot buy and build a drug.
[CUSTOMER][NEUTRAL] There's no carveout list. There's no specialty pharmacy. Prior authorization is not required, um, you stated that.
[CUSTOMER][NEUTRAL] You follow a major medical EOB?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And.
[CUSTOMER][NEUTRAL] Um, this patient effective date is [PII]. This plan runs on a calendar year. It's not fully funded. Is it self-funded then?
[AGENT][NEUTRAL] Mhm. It is.
[CUSTOMER][NEUTRAL] I guess I'm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So it's self funded um so it follows.
[CUSTOMER][NEUTRAL] Um, I know you said it's a gap plan, but I'm not real familiar with a lot of gap plans, and I'm just wondering, does this follow.
[AGENT][NEUTRAL] It's just a supplement to the major medical policy.
[CUSTOMER][NEUTRAL] Right, so does it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You follow their guidelines then?
[AGENT][NEUTRAL] OK, I'm not understanding what you mean. They guidelines, so once they process the claim what.
[CUSTOMER][NEUTRAL] I mean you follow
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hello? Oh, whatever amount the major medical applies towards deductible, co-insurance, and co-pay amounts, um, those are the amounts that we reimburse of covered charges.
[CUSTOMER][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] If that's what you mean by guidelines.
[CUSTOMER][NEUTRAL] Um, I mean, like, is this like an off the shelf product then it's kind of like you like you get what you get or is it customizable? I guess is what I'm saying.
[AGENT][NEUTRAL] I'm not quite understanding what you're saying.
[CUSTOMER][NEUTRAL] It's OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, it's OK. But, um, so, but this is a commercial plan, right? A commercial gap plan? It's not like a Medicare or Medicaid plan.
[AGENT][NEUTRAL] It's not, it's
[AGENT][NEUTRAL] Cigna is commercial. This is a met gap policy, so it's not a commercial plan. Cigna, Aetna, United Healthcare, those are commercial plans.
[CUSTOMER][NEUTRAL] Right, but this is not a Medicaid or Medicare plan, right?
[AGENT][NEUTRAL] This is
[AGENT][NEUTRAL] The supplemental gap policy.
[CUSTOMER][NEUTRAL] Right. OK. Got you. OK. And then I, um I just wanted to verify, I have the group name of Oklahoma Allergy and Asthma Clinic. Could you verify that for me?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK, and group number is 23633.
[AGENT][NEUTRAL] Correct. And what office are you calling on behalf of [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's Oklahoma Allergy and Asthma Clinic.
[AGENT][NEUTRAL] OK, so the services will be rendered at Oklahoma Ay.
[CUSTOMER][NEUTRAL] In [PII] City, [PII].
[CUSTOMER][NEUTRAL] I'm sorry, what's that?
[AGENT][NEUTRAL] I said the services will be rendered at Oklahoma Allergy and asthma clinic.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All righty.
[CUSTOMER][NEUTRAL] OK, and then the claims address is [PII] payer ID is 60801.
[AGENT][POSITIVE] Correct. Mhm.
[CUSTOMER][POSITIVE] OK awesome thank you for your patience um with me and your help. I really appreciate it and then would you happen to have a reference number?
[AGENT][NEUTRAL] You're OK, fine.
[AGENT][NEUTRAL] You'll use my name in today's date as your reference [PII].
[AGENT][NEUTRAL] ONYA first initial last name is [PII]. Did you have any other questions?
[CUSTOMER][POSITIVE] No, ma'am, that's it. Thank you so much.
[AGENT][POSITIVE] Alright, you're welcome thanks for calling APL have a good day.
[CUSTOMER][NEUTRAL] You too bye bye.