AccountId: 011433970860
ContactId: 2f1226b0-515d-4fa6-af55-176d67c054ae
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 535039 ms
Total Talk Time (AGENT): 226497 ms
Total Talk Time (CUSTOMER): 216947 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/25/2f1226b0-515d-4fa6-af55-176d67c054ae_20250325T16:38_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. My name is [PII]. I am a case manager calling from Merk Access program, and please note that this call is being recorded for quality assurance. I am calling today to collect the benefits and eligibility. Would you be able to assist?
[AGENT][POSITIVE] Yeah, I could check benefits and eligibility for you. uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Of course, [PII].
[AGENT][NEUTRAL] OK, thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] Yes, policy number is 024.
[CUSTOMER][NEUTRAL] 787.
[CUSTOMER][NEUTRAL] 76 M as in Mary, L as in Lima.
[CUSTOMER][NEUTRAL] And the number 8.
[AGENT][POSITIVE] Perfect. And then uh what was the name and date of birth for the insured, please?
[CUSTOMER][NEUTRAL] Yes, it is uh I wanna say it's [PII], um [PII]. 1st name is spelled [PII] Last name is [PII] And again, date of birth is [PII].
[AGENT][NEUTRAL] Got it, thank you so much for verifying that information, [PII]. Uh, so this policy is active. Effective date was [PII], and this is a secondary medical policy, so it is designed to help with co-pay, deductible and co-insurance after major medical pays, and we really need to look at, uh, inpatient or outpatient benefits.
[CUSTOMER][NEUTRAL] Um, well I'll be able to check to see if they are inpatient?
[AGENT][NEUTRAL] I'm sorry, what was that?
[CUSTOMER][NEUTRAL] No, wait, I'm so sorry. I said that wrong. Nope, I said that wrong. I was thinking of um network, in-network status. Now, this will be outpatient benefits. But uh before I move forward, is this the, um, I know that you said that this is a secondary, but what type of insurance is this? Is this a um Medicare Advantage, Medicare Supplement?
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] No, nothing like that. So uh this plan is heavily dependent on whoever they have as their primary insurance. So, um, Blue Cross, Cigna, Aetna, um, carriers like that, as long as they are willing to pay, this policy can help with co-pay, deductible and co-insurance if their primary medical, um, does not pay or they're not willing to, this policy can't, um, and it's, uh, there's no network for this plan again, as long as their major medical is willing, this policy can.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so, um, will I be able to provide you codes for the out um outpatient?
[CUSTOMER][NEUTRAL] Benefits.
[AGENT][NEUTRAL] Um, no, I can't look up codes, uh, but I can give you that outpatient benefit amount, um, of course I will let you know that verification of coverage is not a guarantee of payment for claims, uh, so their outpatient benefit is on a per calendar day basis. It pays up to $300 per calendar day and again that goes towards co-pay, deductible and co-insurance.
[CUSTOMER][NEUTRAL] And then go, what was that co-insurance, co-pay, and deductible, is that correct?
[AGENT][NEUTRAL] Uh
[AGENT][POSITIVE] Correct, that's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And this is a member secondary, is that correct?
[AGENT][NEUTRAL] Yes, this is a secondary medical policy.
[CUSTOMER][NEUTRAL] OK, and is this um a calendar year? I know you said calendar day, but does this go off a calendar year? OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right, yeah, um, the outpatient benefit does not have a yearly maximum, um, but it is a per calendar year policy.
[CUSTOMER][NEUTRAL] Or just discounted.
[CUSTOMER][NEUTRAL] And will I need a prior authorization?
[AGENT][NEUTRAL] No authorization is not required.
[CUSTOMER][NEUTRAL] What about a predetermination?
[AGENT][NEUTRAL] No, again, as long as the major medical is willing this policy can.
[CUSTOMER][POSITIVE] Sorry, I'm just writing those. I do apologize for my um silence.
[AGENT][NEUTRAL] Oh, you're fine.
[CUSTOMER][NEUTRAL] I just want to, um, OK, you said $300 per calendar day, that's, um, going towards the co-insurance, co-pay and deductible, and major medical. If they if that plan does cover it, the secondary will cover the rest. Is that correct?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, so it's um again very dependent on major medical um if they don't pay this policy can't, so this policy cannot be used instead of their primary if that makes sense.
[CUSTOMER][NEUTRAL] So primary has to be used first.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And again, you do not take codes to check coverage.
[AGENT][NEUTRAL] No, um, but what, what was it? I could kinda give you an idea is it for a specific procedure?
[CUSTOMER][NEUTRAL] Yes, J 9271 and then there was a diagnosis of C 50.912.
[AGENT][NEUTRAL] What were those? Um, is this for a surgery? I don't have a way to look up codes, unfortunately.
[CUSTOMER][POSITIVE] Oh, no. Oh yes, I do apologize. That was for a um chemotherapy injection.
[AGENT][NEUTRAL] Email, OK, OK, um, so yeah, unfortunately I'm unable to look up codes um and uh you know it really would go down to whether you know once you file the claim we'll have the more specific information um what kind of environment would that be in? Is that a physician's office or is this in a hospital setting?
[CUSTOMER][NEUTRAL] This will be outpatient hospital, yeah.
[AGENT][NEUTRAL] Hospital. OK, OK, so this policy does not have treatment for um in office. It does regarding cancer though, so yes, that's that's gonna be, that should be covered.
[CUSTOMER][NEUTRAL] Now, can this be buy and bill or does it need to go to a specialty pharmacy?
[AGENT][NEUTRAL] I'm so sorry, could you repeat that?
[CUSTOMER][NEUTRAL] Yeah, of course. Can they buy and bill with um APL or does it have to go to a, I'm sorry, a um AMP or do they have to go to a specialty pharmacy?
[AGENT][NEUTRAL] That's OK, no, no, it shouldn't have to require anything specific like that.
[CUSTOMER][NEUTRAL] OK. And does this plan have a deductible or out of pocket?
[AGENT][NEGATIVE] It does not.
[CUSTOMER][NEUTRAL] Does this plan follow any guidelines like NCCN guidelines?
[AGENT][NEUTRAL] Just major medical guidelines.
[CUSTOMER][NEUTRAL] And does this
[CUSTOMER][NEUTRAL] Um, policy have any medical benefits. So the the benefits you have provided me was a medical, is that correct?
[AGENT][NEUTRAL] Yes, yes, this is all uh strictly medical.
[CUSTOMER][NEUTRAL] And then, um, well this, the chemotherapy that you stated that will be $300 paid out calendar day, would that be for the same for immunotherapy, that is another type of cancer treatment?
[AGENT][NEUTRAL] Yes, that's for any kind of outpatient treatment in general, um, so they do have a separate inpatient benefit, but anything that would be uh considered outpatient would be that up to $300 per calendar day.
[CUSTOMER][NEUTRAL] Is there an annual benefit max or any lifetime max?
[AGENT][NEUTRAL] No, not for outpatient.
[AGENT][NEUTRAL] It's just that daily maximum.
[CUSTOMER][NEUTRAL] Any limits or restrictions besides the 300 per calendar day.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] And um will I be able to check to see if this provider was in network?
[AGENT][NEUTRAL] This plan uh is not affiliated with any network again it just follows major medical.
[AGENT][NEUTRAL] If major medical would cover it, this policy can.
[CUSTOMER][POSITIVE] All righty, I believe that it's all the questions that I have for you today. Um, thank you so much for taking your time and, um, explaining this for me and providing me the information.
[AGENT][NEUTRAL] Of course.
[AGENT][MIXED] You are very welcome. It can be a bit confusing.
[AGENT][NEUTRAL] Was there anything else I can help you with?
[CUSTOMER][NEUTRAL] Yes, um.
[CUSTOMER][NEUTRAL] Just a call reference number and that will be it.
[AGENT][NEUTRAL] Sure, yeah, that would just be my first name, last initial, and today's date. Uh, so my name is spelled [PII]
[CUSTOMER][POSITIVE] Perfect. And you said today's date, is that correct?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][POSITIVE] OK, perfect. All right. Well, thank you so much for taking my call today. You have a wonderful day and have a great rest of the week.
[AGENT][POSITIVE] Of course, yeah, thanks for calling APL. You too, bye bye.
[CUSTOMER][NEUTRAL] Yeah.