AccountId: 011433970860
ContactId: 6afbe000-1392-461e-a932-1b9935c84e96
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 736070 ms
Total Talk Time (AGENT): 254963 ms
Total Talk Time (CUSTOMER): 206906 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/15/6afbe000-1392-461e-a932-1b9935c84e96_20250115T22:16_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII], and I'm calling on a recorded line to verify benefits for a patient who's coming into the office for infusion therapy, and I have some procedure codes I need the benefits for.
[AGENT][POSITIVE] All right. I'm happy to take a look. Do you have the patient's policy number, [PII]?
[CUSTOMER][NEUTRAL] It's D like Delta 43732049.
[AGENT][NEUTRAL] OK, um, I unfortunately can't pull them with that number. Do you have their name or social? I can check for him that way.
[CUSTOMER][NEUTRAL] Um, the name is [PII]. Last name is [PII] with the date of birth [PII].
[AGENT][POSITIVE] Alright, thank you so much let me do a search by that one moment.
[AGENT][NEUTRAL] All right. So, patient does have an active plan with us. It looks like the effective date on this is [PII].
[AGENT][NEUTRAL] And [PII], do you need the uh policy number?
[CUSTOMER][NEUTRAL] Yeah, I'll take it.
[AGENT][NEUTRAL] Alright, our policy number is gonna be 0255.
[AGENT][NEUTRAL] 7396.
[CUSTOMER][POSITIVE] Alrighty.
[AGENT][NEUTRAL] So the patient has what we call a limited benefit medical plan. It's a hospital indemnity plan. It's gonna pay just a set amount depending upon what the patient is being seen for. So,
[AGENT][NEUTRAL] And you said it was an infusion therapy?
[CUSTOMER][NEUTRAL] Mhm. It's for infusion therapy done in the office, administered by the provider, and offices that isn't billed, it's not related to cancer, and the medication that will be used is Symbony Aria.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] So you said there was no office visit though that will be billed, correct?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So the plan just shows that it has a benefit for for an office visit, and then it has a surgical and anesthesia benefit. I don't know if it would fall under surgical though. Let me see.
[AGENT][NEUTRAL] And then just hospital, like if they were in the hospital.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So it doesn't say you would cover infusion therapy?
[AGENT][NEUTRAL] There's nothing specifically that speaks to infusion therapy. Um, under the benefits as far as like definitions, it does say that we will pay a surgical benefit whenever the insured or dependents, um,
[AGENT][NEUTRAL] If it's performed on an inpatient or outpatient basis in a physician's office or ambulatory surgical center.
[CUSTOMER][NEUTRAL] I don't think that's us. Can I get the office benefit?
[AGENT][NEUTRAL] Uh, the benefit for that is $75 per visit and it allows the patient a total of
[AGENT][NEUTRAL] So many visits in a year. Let me double check the amount of visits. One moment.
[AGENT][NEUTRAL] Looks like they're allowed up to 4 visits in a calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is there any deductibles out of pockets, copays, or co-insurance on this plan?
[AGENT][NEUTRAL] No, there is not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] OK, do you guys cover.
[CUSTOMER][NEUTRAL] Medical injectable drugs.
[AGENT][NEUTRAL] Yeah, so I don't see the only thing, there's nothing on here for like any sort of pharmacy or medical like coverage. It's just basically an outpatient plan um for office visits and then any sort of confinement in a hospital or wellness or diagnostic testing.
[CUSTOMER][NEUTRAL] OK, um, I have some questions I have to ask you if you don't know the answer or that's not available on the plan that's totally OK.
[CUSTOMER][NEUTRAL] Um, can we buy and bill the, can we buy and bill the drug the symphony AA under the medical benefits?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, yes, you should be able to.
[CUSTOMER][NEUTRAL] OK, can we buy and bill every time the patient is infused?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Is there a carveout list of drugs we cannot buy and bill under the medical benefit of the plan?
[AGENT][NEUTRAL] Not that I'm aware of.
[CUSTOMER][NEUTRAL] Uh, is there a specialty pharmacy on this plan?
[AGENT][NEUTRAL] No, there is not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is prior authorization required for the services or any of the um.
[CUSTOMER][NEUTRAL] Or the J code.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, I have to follow up with this prior authorization optional.
[AGENT][POSITIVE] Bless you.
[CUSTOMER][POSITIVE] Thanks.
[AGENT][NEUTRAL] Yeah, I mean any sort of prior authorization is optional, it's not required.
[CUSTOMER][NEUTRAL] OK, where would we send a prior authorization?
[AGENT][POSITIVE] I can give you a mailing address or a fax number, whatever works best for you.
[CUSTOMER][NEUTRAL] I'll take the fax number.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] All right, and can I also get the physical address?
[AGENT][NEUTRAL] For like claims?
[CUSTOMER][NEUTRAL] Or did you say email?
[AGENT][NEUTRAL] Are you talking about like for claim?
[CUSTOMER][NEUTRAL] Did you say a fax or an email?
[AGENT][NEUTRAL] I said we, I'm sorry, we have a fax or a mailing address, like a physical mailing.
[CUSTOMER][NEUTRAL] Can I get that?
[AGENT][NEUTRAL] Yeah, absolutely, it's [PII].
[AGENT][NEUTRAL] And that's in [PII].
[CUSTOMER][NEUTRAL] Alrighty, and is there a phone number we can use to check status and initiate?
[AGENT][NEUTRAL] Um, you, the number you had called, that's a good contact number. It is the [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, is there a prior authorization attached to that phone number department?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, um, is there a portal we can initiate through?
[AGENT][NEUTRAL] Uh, we do have a portal at [PII] for providers.
[CUSTOMER][NEUTRAL] Alrighty, is there an authorization on file for the drug?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, oh, what? OK, um, can you confirm the provider is in network?
[AGENT][NEUTRAL] On this plan it looks like there's not any sort of network required so they can use they should be able to use it anywhere.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you confirm you guys are the primary insurance?
[AGENT][NEUTRAL] No, we cannot. We don't have that information.
[CUSTOMER][POSITIVE] Alrighty.
[CUSTOMER][NEUTRAL] Is this a calendar your plan?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Is it fully funded or self funded?
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][POSITIVE] Looks like fully funded.
[CUSTOMER][NEUTRAL] Does this policy follow the rules of the health plan?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. And is primary care referral required?
[AGENT][NEGATIVE] No, it is not.
[CUSTOMER][NEUTRAL] And then this is a commercial indemnity, correct?
[AGENT][POSITIVE] Mhm. Correct.
[CUSTOMER][NEUTRAL] OK, can I get the group name and group number for billing?
[AGENT][NEUTRAL] Yeah, so the group name is Man analysis and utilization.
[AGENT][NEUTRAL] And the group number is 70056.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Alrighty, is there a plan name, number, or description other than these two things?
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] And can I get the, is the mailing address you gave me also the claims address?
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Perfect. OK, so just to verify you guys pay 70 $75 towards an office visit for 4 visits per year. There's nothing specific to any infusion therapy or any medical injectable drugs. There's no copay, co-insurance, deductible, or out of pocket on this plan. Buying bill is allowed, no limits, no carve out. Prior authorization is not required, but it is optional, and there's no authorization on file. Is that correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, can I get a reference number from you?
[AGENT][NEUTRAL] Absolutely, [PII]. It's gonna be my name with my last initial and then today's date. My name again is [PII], that's [PII] Last initial to my name is [PII].
[CUSTOMER][POSITIVE] Great thank you so much have a good day.
[AGENT][NEUTRAL] You too bye bye.