AccountId: 011433970860
ContactId: 736e4dc0-26bd-4c3b-8923-cc9cc6e2c7db
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 788909 ms
Total Talk Time (AGENT): 271522 ms
Total Talk Time (CUSTOMER): 319860 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=3.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/01/736e4dc0-26bd-4c3b-8923-cc9cc6e2c7db_20250501T12:39_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, good morning, [PII]. My name is [PII]. First initial to my last name is [PII]. I'm calling on a recorded line to verify benefits for a patient coming in for infusion, and I do need to verify coverage for specific procedure codes.
[AGENT][NEUTRAL] OK, we don't use procedure codes, but I can help you with the benefits. And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][POSITIVE] Awesome.
[CUSTOMER][NEUTRAL] Of course that's [PII] and that will be a direct line as well.
[AGENT][NEUTRAL] OK. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yeah, that will be 01611637 followed by M for Mary, L Lima, then the number 8.
[AGENT][NEUTRAL] Thank you, hold on one moment. 37.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, that's [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So I am showing the policy is active, it's been effective since [PII], and the infusion, is it going to be inpatient or is this outpatient?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So it will take place in the specialist office um we just won't be billing for the office visit so it will be outpatient um and as well with that treatment that it's just not gonna be related to cancer.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, hold on one moment. I'm just waiting for the um schedule of benefits to populate. Hold on one second.
[CUSTOMER][POSITIVE] Of course, thank you.
[CUSTOMER][NEUTRAL] Of course.
[AGENT][NEUTRAL] OK, so for outpatient, the policy would pay up to $1500 per calendar year. Um, now the policy itself doesn't have like any office setting coverage, but she does have the office treatment writer, so any treatment in the office as long as it's not cosmetic, could be covered up to that $1500 per year. Did you want me to see if she's used any of that?
[AGENT][NEUTRAL] Hello.
[CUSTOMER][MIXED] That would be awesome sorry my line was a little bit cutting in and out on you. Sorry about that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That's OK.
[AGENT][NEUTRAL] No, you're fine. OK, hold on one moment let me check for you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] So it's 1500, let me see if she.
[AGENT][NEUTRAL] So she's only used $50 so she has $1450 left for 2025.
[CUSTOMER][POSITIVE] Awesome.
[CUSTOMER][POSITIVE] Perfect and you said she's only used $50 of that?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] Awesome, and is that just gonna be, um, is she just gonna be covered at 100% up into that 1500 of the benefits max?
[AGENT][NEUTRAL] Will she be covered up to 100% up to that. So it depends on what's received. So we're her secondary insurance. So, um, once we see the explanation of benefits from primary, we'll see if she had to pay anything upfront to be reimbursed or if there's anything still owed to y'all. So it depends on um what all is left after primary, but
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I don't want to say it'll be 100% because, because I don't know what's gonna come in.
[AGENT][NEUTRAL] But she does have that uh balance.
[CUSTOMER][POSITIVE] Awesome. OK
[CUSTOMER][POSITIVE] Awesome perfect so um is that does that kind of act as her like deductible by chance?
[AGENT][NEUTRAL] Uh, we pay towards the copay.
[CUSTOMER][NEUTRAL] Do you know, um, because I know that they do have to.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We pay towards the copay, deductible and co-insurance after primary, so primary applies it and we help pay it.
[CUSTOMER][NEUTRAL] Towards the
[CUSTOMER][POSITIVE] Help pay it awesome thank you and you said copay after that 1500 and she's met 50 so far.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Awesome and just to confirm that 1500 is just gonna act as her benefits maximum?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] To an extent
[CUSTOMER][POSITIVE] Awesome OK perfect thank you for clarifying on that. I do appreciate it.
[AGENT][POSITIVE] You're very welcome.
[AGENT][NEUTRAL] Well, was there anything else I can assist you with today? I'm sorry.
[CUSTOMER][NEUTRAL] And as well with um.
[CUSTOMER][NEUTRAL] No, I don't, no need to apologize. Um, I do have another question for the service. Do you know if authorization would also be required for the service as well?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So we don't require any prior author pre-cert because we're not a major medical insurance company.
[CUSTOMER][POSITIVE] Awesome perfect.
[CUSTOMER][NEUTRAL] And just to confirm, with no authorization being required, there's nothing currently listed on file as well, is that correct?
[AGENT][NEUTRAL] Nothing currently listed on file in terms of
[AGENT][NEUTRAL] Like what
[CUSTOMER][NEUTRAL] Just like any authorizations or referrals.
[AGENT][NEGATIVE] Oh, no, not for us. Uh, no, we don't, we don't work with them. We don't require them.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Awesome.
[CUSTOMER][POSITIVE] Beautiful. And then as well, can we buy and build the drug under the medical benefit?
[AGENT][NEUTRAL] So we only um if it's administered?
[AGENT][NEUTRAL] In office and it's and it's, you know, charged, then yes, we would um cover it, but we only do the administrating, we don't do the the billing.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So if it was administered as a treatment, then
[CUSTOMER][NEUTRAL] OK, only the administra.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Awesome and just to confirm as well, um, can we buy and build the drug every time the patient is infused? Like, is there any limitation within that as well?
[AGENT][NEUTRAL] Just that max.
[CUSTOMER][POSITIVE] Just the max awesome.
[AGENT][NEUTRAL] The 1500 max.
[CUSTOMER][POSITIVE] Beautiful and as well as there a carve out list of drugs not allowed under the medical benefit for this plan?
[AGENT][NEGATIVE] No, because we don't really do, we don't, so it's not, how can I explain this? We don't really bill, well, we don't pay out.
[CUSTOMER][NEUTRAL] Is that just more based on primary?
[AGENT][NEUTRAL] Right, so these questions are really for primary, but secondary, no, we don't, um.
[CUSTOMER][POSITIVE] Got you.
[AGENT][NEUTRAL] If it comes in as a service or a treatment that was administered, then we'll pay towards it, but like we don't have a list of prescriptions, all of that, that's primary.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] That's right.
[CUSTOMER][POSITIVE] Awesome thank you.
[CUSTOMER][NEUTRAL] And then as well does it show if the patient carries a specialty pharmacy?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] No, but let me double check.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] No, there's no specialty pharmacy.
[AGENT][NEUTRAL] It's more so the outpatient and inpatient facilities and
[CUSTOMER][NEGATIVE] No specialty form
[AGENT][NEUTRAL] Not really treatment and what's done is where.
[CUSTOMER][POSITIVE] Gotcha. Awesome. And I just see that you guys are secondary to United Healthcare, is that correct on my end?
[AGENT][NEUTRAL] Um, let me double check, hold on one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, I'm 29 Healthcare.
[CUSTOMER][POSITIVE] Awesome thank you and you guys are uh don't work off of providers network status is that correct?
[AGENT][NEUTRAL] Right, there's no network for secondary.
[CUSTOMER][POSITIVE] Beautiful and is this plan fully or self funded as well?
[AGENT][NEUTRAL] Let me see, hold on one moment.
[CUSTOMER][POSITIVE] Mhm thank you.
[AGENT][POSITIVE] It's fully funded.
[CUSTOMER][NEUTRAL] Thank you and then you all follow primary guidelines and then is a PCP referral required?
[AGENT][NEUTRAL] That's primary also, um, we don't require referrals.
[CUSTOMER][POSITIVE] Awesome.
[CUSTOMER][POSITIVE] Beautiful and then as well, is there a group name listed underneath the patient's plan for billing purposes?
[AGENT][NEUTRAL] Um, hold on one moment. Let me get it for you. Is City [PII]?
[CUSTOMER][POSITIVE] Thank
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Awesome and just to confirm that [PII]'s just gonna be the [PII], is that correct?
[AGENT][NEUTRAL] Yes. Mhm.
[CUSTOMER][POSITIVE] Awesome and do they also carry a group number as well or just that name?
[AGENT][NEUTRAL] No, there's a group number. Um, it's 22392.
[CUSTOMER][NEUTRAL] Thank you and is there any like coverage description or plan name associated with her as well?
[AGENT][NEUTRAL] Well, uh, plan name is a Medlink supplemental gap insurance.
[CUSTOMER][POSITIVE] Supplemental gap insurance, thank you.
[CUSTOMER][NEUTRAL] And then just for my last request, could I possibly receive a good claims address and EDI number as well?
[AGENT][NEUTRAL] EDI as in like the payer ID?
[AGENT][NEUTRAL] For, OK. So the um mailing address is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Awesome. And does the patient carry like a a payer ID as well?
[AGENT][NEUTRAL] Yes, the pay ID is 60801.
[CUSTOMER][NEUTRAL] 60801.
[CUSTOMER][POSITIVE] Awesome.
[CUSTOMER][POSITIVE] Perfect and then I think this is everything I need if it is OK with you. I'm just going to do a brief recap of our conversation before we get to that reference if that's all right.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] Awesome, so we just have a patient will be covered up into the $1500 benefit maximum which they have used $50 so far and you guys will cover the co-insurance, co-pay and deductible as well, um, and then they do have that office treatment coverage since there's no office visit coverage, no authorization is required, nothing is on file as well. We can buy and bill there's no limitation.
[CUSTOMER][NEUTRAL] That is based on primary as well as that carve out list is based on primary as well. You guys are secondary to United Healthcare. There's no designated specialty pharmacy. We can confirm that effective date being [PII], running on a calendar year, being self-funded follows primary guidelines, and also that PCP referral will also follow primary guidelines as well, and we can confirm that group name, number, plan description, claims address, and payer ID as well.
[AGENT][NEUTRAL] Yes, the only thing I would want to change because I looked it up just to see like our verbiage. So for buying bill for the type of policy she has, we're just gonna say there's no benefits for medication.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Because I wanted the verbs to be correct.
[CUSTOMER][POSITIVE] No benefits for medication. OK, awesome. So that would just be more uh based on primary as well um for that question to be directed. Beautiful. Awesome.
[AGENT][NEUTRAL] Primary.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] Thank you Miss and then beautiful if I could just then receive an awesome reference and it should be all set.
[AGENT][NEUTRAL] Alright, so there's no call reference number, but you can use my name in today's date, and that's [PII] to my last name is [PII].
[CUSTOMER][POSITIVE] Awesome well thank you so much for your time [PII] and have a beautiful week ahead as well.
[AGENT][POSITIVE] Thank you, [PII]. You also, and thanks for calling APL. Was there anything else I could help with?
[CUSTOMER][POSITIVE] Um, that should be everything, thank you.
[AGENT][POSITIVE] Alright have a great day. You're welcome.
[AGENT][NEUTRAL] Bye bye.