AccountId: 011433970860
ContactId: 3d97e868-9016-4045-a06e-23235c56f933
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1291329 ms
Total Talk Time (AGENT): 127174 ms
Total Talk Time (CUSTOMER): 242113 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.2, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/05/3d97e868-9016-4045-a06e-23235c56f933_20250605T19:05_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII], calling on behalf of the Amgen Support Plus program on a recorded line for training and quality assurance. I'm calling to verify medical benefits for patient [PII], who is a mutual patient of Dr. [PII].
[AGENT][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] What's the policy number?
[CUSTOMER][NEUTRAL] The patient's ID number is 01936871.
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] Patient's date of birth is [PII].
[AGENT][NEUTRAL] Are you looking for eligibility?
[CUSTOMER][NEUTRAL] I'm calling to verify a network benefits for an injection of Prolia with procedure code J0897. The administration code is 96372, and the diagnosis code is M81.0 administered in a specialist office. First, could you spell out your first name and provide the initial of your last name, please?
[AGENT][NEUTRAL] Give me just one moment please.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What provider are you calling for?
[CUSTOMER][NEUTRAL] I'm calling at the request of the provider with first name [PII] spelled [PII] Last name [PII] spelled [PII]
[AGENT][NEUTRAL] And a callback number?
[CUSTOMER][NEUTRAL] My direct callback number is [PII]. No extension is required.
[AGENT][NEUTRAL] Please repeat.
[CUSTOMER][NEUTRAL] My direct callback number is [PII]. No extension is required.
[AGENT][NEUTRAL] To verify, I have [PII].
[CUSTOMER][NEUTRAL] My direct callback number is [PII]. No extension is required.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] 4
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] 2
[CUSTOMER][NEUTRAL] 3
[CUSTOMER][NEUTRAL] 4
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Can you verify the policy number?
[CUSTOMER][NEUTRAL] The patient's ID number is 01936871.
[AGENT][NEUTRAL] Are you calling for eligibility?
[CUSTOMER][NEUTRAL] First, I have some general plan questions. Can we please proceed with those before verifying benefit information?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] What is the policy effective date?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Is the plan active?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] What is the plan name?
[AGENT][NEUTRAL] Meddling 6.
[CUSTOMER][NEUTRAL] What type of plan is this?
[AGENT][NEUTRAL] Secondary gap insurance.
[CUSTOMER][NEUTRAL] Is this a commercial or Medicare Advantage plan?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Is it a PPO, POS, or HMO plan?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Is this a government funded plan such as Medicaid or Medicare?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Just a moment please. for billing purposes, what is the group number?
[AGENT][NEUTRAL] 12696.
[CUSTOMER][NEUTRAL] What is the group name?
[AGENT][NEUTRAL] City of Electra.
[CUSTOMER][NEUTRAL] Is this a cobra plan?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Does this run on benefit or calendar year?
[AGENT][NEUTRAL] Repeat.
[CUSTOMER][NEUTRAL] Does this run on benefit or calendar year?
[AGENT][NEUTRAL] Can you verify you are HIPAA compliant?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Please verify.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Does this run on benefit or calendar year?
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Calendar year.
[CUSTOMER][NEUTRAL] Is this plan self-funded or fully insured?
[AGENT][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] Is a referral required from the primary care physician to see a specialist?
[AGENT][NEGATIVE] Not for this policy.
[CUSTOMER][NEUTRAL] Our records indicate that this member has another insurance policy. What is the name of the other insurance?
[AGENT][NEUTRAL] Are you asking for their primary insurance carrier?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Blue Cross
[CUSTOMER][NEUTRAL] Is this a non-duplication plan?
[AGENT][NEUTRAL] This is secondary insurance.
[CUSTOMER][NEUTRAL] How do you coordinate benefits by non-duplication of benefits or come out whole or standard COB?
[AGENT][NEUTRAL] I don't know.
[AGENT][NEUTRAL] Are you wanting eligibility?
[CUSTOMER][NEUTRAL] Can you please explain how this plan coordinates benefits with the primary insurance?
[AGENT][NEUTRAL] Primary insurance pays first, we pay 2.
[CUSTOMER][NEUTRAL] Is this a non-duplication plan?
[CUSTOMER][NEUTRAL] Non-duplication of benefits is when if a patient has two plans. The secondary plan will not pay any benefit if the primary plan paid the same or more than what the secondary plan allows. Is this a non-duplication of benefits plan?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] If the primary insurance denies, will this plan consider covering his primary?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] What is the individual deductible for this plan and how much has been met?
[AGENT][NEUTRAL] This is a verification of benefits, not a guarantee of payment.
[AGENT][NEUTRAL] Inhospital deductible and outpatient deductible, $0 per calendar year.
[CUSTOMER][NEUTRAL] Is there a family deductible?
[AGENT][NEGATIVE] No deductible.
[CUSTOMER][NEUTRAL] What is the individual out of pocket maximum and how much has been met?
[AGENT][NEUTRAL] No out of pock
[CUSTOMER][NEUTRAL] Outpatient service in a specialist office.
[AGENT][NEUTRAL] This is a verification of benefits, not a guarantee of payment. Outpatient benefit maximum of up to $4000 per covered person per calendar year.
[CUSTOMER][NEUTRAL] And how much has been met?
[AGENT][NEUTRAL] 1300.
[AGENT][NEUTRAL] The $83.21.
[AGENT][NEUTRAL] To date
[CUSTOMER][POSITIVE] OK, great.
[AGENT][NEUTRAL] Anything else?
[AGENT][NEUTRAL] Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] Is there a true copay or co-insurance for J0897?
[AGENT][NEUTRAL] I can't look up codes.
[CUSTOMER][NEUTRAL] Just a moment, please.
[CUSTOMER][NEUTRAL] Is there a standard plan letter for this patient's supplemental plan?
[AGENT][NEUTRAL] A policy certificate?
[CUSTOMER][NEUTRAL] Is there a standard plan letter for this patient's supplemental plan? Can you check that, please?
[AGENT][NEUTRAL] Repeat.
[CUSTOMER][NEUTRAL] Is there a standard plan letter for this patient's supplemental plan?
[AGENT][NEUTRAL] There is a proof of coverage letter.
[CUSTOMER][NEUTRAL] Just a moment, please.
[CUSTOMER][NEUTRAL] Does the patient have Medicare Part B?
[AGENT][NEUTRAL] I can't see that information.
[CUSTOMER][NEUTRAL] Will this plan cover the Part B deductible?
[AGENT][NEUTRAL] This plan helps with co-insurance, co-pay, and co-deductible.
[CUSTOMER][NEUTRAL] Is there a true co-pay or co-insurance for J0897? Prolia is one prefilled syringe of 60 mg, an injection for osteoporosis.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] I'm not seeing that covered.
[CUSTOMER][POSITIVE] Thanks so much for your help today. Have a great day. Bye.