AccountId: 011433970860
ContactId: 49b33ccf-a9ec-49c2-9d32-f58bca82fbee
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 628340 ms
Total Talk Time (AGENT): 120037 ms
Total Talk Time (CUSTOMER): 394392 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/49b33ccf-a9ec-49c2-9d32-f58bca82fbee_20250121T14:35_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. Last initial is [PII] hotel. I am calling on a recorded line and I'm just calling to verify benefits for a patient that's coming into the office for infusion therapy. I have specific procedure codes.
[AGENT][NEUTRAL] I can verify benefits, [PII], may I have a policy number?
[CUSTOMER][NEUTRAL] Yes, ma'am. That is 0161168.
[CUSTOMER][NEUTRAL] 4
[CUSTOMER][NEUTRAL] And then the letters M Michael L Lima.
[CUSTOMER][NEUTRAL] And then the number 8.
[AGENT][POSITIVE] Thank you, may I have a good call back number for you?
[CUSTOMER][NEUTRAL] Yes ma'am, that's [PII].
[CUSTOMER][NEUTRAL] 350.
[CUSTOMER][NEUTRAL] [PII] and that's a direct line so if the connection gets spotty feel free to give me a call back I'll.
[CUSTOMER][POSITIVE] Got you.
[AGENT][NEUTRAL] Thank you. May I have the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure, her name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you for verifying that information. Please be advised the verification of coverage does not guarantee the payment of a claim. And where would the place of service be?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's gonna be places service 11, a specialist office.
[AGENT][NEUTRAL] OK, this plan will pick up the co-pays, the co-insurance and our deductibles for office treatment. Outpatient calendar year allows 1500.
[CUSTOMER][NEUTRAL] OK, and is that the benefit maximum 1500?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh does that apply to their um.
[CUSTOMER][NEUTRAL] What is that benefit maximum applied to is that gonna be for their deductible or?
[AGENT][NEUTRAL] It will pick up the deductible, the co-insurance, and or uh pay for, yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Deductible, car insurance, and any co-pays, OK. And um have they met anything of that benefit maximum yet? Have they used anything?
[AGENT][NEGATIVE] No benefits have been applied for 2025.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, got you.
[CUSTOMER][NEUTRAL] And then let's see I'm just reading this note about.
[CUSTOMER][NEUTRAL] The benefit max one primary processes.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, and once they um use their benefit maximum of 1500, they will be fully responsible for any remaining balance from the primary payer?
[AGENT][POSITIVE] That is correct.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Are you, do you have access to what that benefit would be or for what they would be responsible for after the benefit maximum?
[AGENT][NEUTRAL] Any services rendered once the benefit max is met, if they have a co-pay or co-insurance, that would be on them to um pay that amount because the 1500 has been exhausted.
[CUSTOMER][NEUTRAL] Right, OK, so you don't know, you wouldn't be able to tell me what the like the coinsurance up to the out of pocket would be or something like that.
[AGENT][NEUTRAL] No, we follow primary.
[CUSTOMER][NEUTRAL] OK, got you.
[CUSTOMER][NEUTRAL] All right, thank you for confirming and then just a couple more questions um do you all take procedure codes?
[AGENT][NEUTRAL] Oh, yes.
[CUSTOMER][NEUTRAL] OK, I do have I do have some do you mind if I uh just give them to you just so you could check some other information for me?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Alright, so the drug is called Evanity and that code is J [PII].
[CUSTOMER][NEUTRAL] The administration code is 963-72.
[CUSTOMER][NEUTRAL] And the diagnosis code is M 81.0. That is for the diagnosis of osteoporosis. And just a quick disclaimer that this is not related to cancer or chemotherapy. Treatment will be performed, like I mentioned earlier in a specialist office and uh we bill professionally, so we don't bill for office visits.
[CUSTOMER][NEUTRAL] Um, does that change anything about the benefit or the benefit max that you provided?
[AGENT][NEGATIVE] No, ma'am. It does not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, and then were you able to tell me if prior authorization is required?
[AGENT][NEUTRAL] It is not required.
[CUSTOMER][NEUTRAL] All right, and would a predetermination be required or recommended?
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then let's see, are we able to buy and build this drug under the medical benefit?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] We are
[CUSTOMER][NEUTRAL] OK. And are we able to buy and build the drug every time the patient comes in for treatment?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is there a list of drugs like a carve out list or a lockout list that are excluded from the buying belt option?
[AGENT][NEUTRAL] We do not have a list. No, we do not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is there a preferred specialty pharmacy on file?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] No, OK.
[CUSTOMER][NEUTRAL] And just a couple more questions. Are you able to confirm.
[CUSTOMER][NEUTRAL] One sec, um, the funding type is this gonna be a self funded plan or fully funded?
[AGENT][NEUTRAL] This is self-funded. This is through their employer.
[CUSTOMER][NEUTRAL] OK, self funded and follows the employers' guidelines?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is there a PCP referral required?
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] L PCP.
[CUSTOMER][NEUTRAL] OK, so that's everything I needed to confirm. The only thing I'm just gonna look into really quick is it looks like previously we've been told we cannot buy and build a drug under the medical benefit. So I just want to look into that a little bit, um, and ask if you would be able to just get a second verification on that.
[CUSTOMER][NEUTRAL] Just so I could update it if if that has changed if we can now buy a bill.
[AGENT][NEUTRAL] OK, because this plan follows the primary.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] So let me verify there's nothing new in our system.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So as far as buying bill requirements, um, that is up to the primary insurance?
[AGENT][NEUTRAL] Correct, cause we will follow primary. So if primary pays this plan as long as they have the benefits.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me just look one more spot and then that should be it and I'll just go ahead and give you a quick summary and then I'll grab a reference number for the call.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, it looks like um for the benefit, we did confirm today that for the drug Avanity J Juliet 3111 for infusion therapy um that
[CUSTOMER][NEUTRAL] This plan um.
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] OK, so this plan will pay up to $1500 of a benefit maximum um towards the patient's remaining financial responsibility from the primary payer. Once the patient uses up and meets that benefit max of $1500 they are responsible for any remaining balance from the primary payer. Um, so far they have met $0 of the $1500.
[CUSTOMER][NEUTRAL] And um as for prior authorization, you did confirm that that is not required for this drug and pre predetermination is also not recommended or required. There's no prior author pretty on file because of this. Um, we are able to buy and bill this drug under the medical benefit. You did confirm that, um, you will follow the primary guidelines with this. So if they say we can buy and bill, then we can buy and bill.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And then for a carve out list there was no carve out list of excluded drugs and the specialty pharmacy was not available um we were unable to confirm that and then you lastly confirm that this is a self funded plan. It follows the employer's guidelines and there is no PCP referral required.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, and lastly this is kind of redundant but I did forget to officially confirm that this is a gap plan, correct?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK, got you. Alright, Miss [PII], then I will just take your reference number for the phone call if you got one.
[AGENT][NEUTRAL] Yes, it will be my name which is [PII] Last initial is [PII] along with today's date. [PII], is there anything else I can assist you with?
[CUSTOMER][POSITIVE] That should be it thank you so much for all the help.
[AGENT][POSITIVE] You're so welcome, and thank you for calling American Public Life, [PII]. Have a great day. Bye-bye.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][NEUTRAL] Bye bye.