AccountId: 011433970860
ContactId: 76aabf93-aeb6-478c-87f2-0d10f85f18e1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 465410 ms
Total Talk Time (AGENT): 190550 ms
Total Talk Time (CUSTOMER): 182956 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/76aabf93-aeb6-478c-87f2-0d10f85f18e1_20250219T13:36_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. My name is [PII] calling on a recorded line. I'm just needing to verify benefits for a patient coming into the office for infusion therapy, um, and I just have specific CPT codes to verify.
[AGENT][NEUTRAL] OK, [PII], you're needing to verify benefit information for treatment done in the office. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, yes, ma'am. I can help you with that. And [PII], do you know, do you also need eligibility for this number?
[CUSTOMER][NEUTRAL] Um, no, I do not.
[AGENT][NEUTRAL] OK, I can help you. And what is your callback number please, [PII]?
[CUSTOMER][NEUTRAL] Yeah it's a direct line it's [PII].
[AGENT][NEUTRAL] OK. Did you say [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you. And the member's policy number please, [PII]?
[CUSTOMER][NEUTRAL] It's 01792121.
[AGENT][NEUTRAL] OK, thank you. One moment, please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Just one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hey, oh, excuse me, [PII].
[AGENT][POSITIVE] I'm so sorry about that.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] So any information that I provide for you today would be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII] [PII].
[AGENT][NEUTRAL] OK, thank you. Now this is a supplemental policy to his primary insurance that helps with co-pays, deductibles and co-insurance amounts of coverage services. So on this policy, he does have an office treatment writer.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Which can be reviewed under his outpatient benefits and his outpatient.
[AGENT][NEUTRAL] Combined calendar year benefit is 5 maximum benefit is $5000 for covered outpatient services.
[AGENT][NEUTRAL] And there is no outpatient deductible per covered person per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, perfect. And I know you don't take codes, but is it OK if I just give you a description?
[AGENT][NEUTRAL] And when
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] We will have to have a copy along with your claim of the primary insurance company's explanation of benefits to review.
[AGENT][NEUTRAL] I won't be able to tell you if it's covered until we receive the claim and their primary EOB.
[CUSTOMER][NEUTRAL] OK, um, well then.
[CUSTOMER][NEUTRAL] OK. All right. Um, well then I do just wanna let you know that the medication is testpire. Um, it's not related to cancer. It is gonna take place in the specialist office and the place of service is 11, but it just won't be billed as an office visit. It would be billed professionally.
[AGENT][NEUTRAL] So he does have an office treatment rider. Yes, ma'am. Office visits are not covered, but he does have an office treatment writer.
[CUSTOMER][NEUTRAL] Um, I have noticed.
[AGENT][NEUTRAL] For treatment rendered within the office.
[CUSTOMER][POSITIVE] OK, perfect.
[AGENT][NEUTRAL] And then once we have processed our claim, [PII], we do have a portal in which you should be able to check claim status by going to secured.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] That's [PII].
[AGENT][NEUTRAL] Yes, ma'am. Uh-huh.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] Um, and then for buying bill you would just follow the primary guidelines, correct?
[AGENT][NEUTRAL] Um, let me check. There's no medication benefits under this policy. This policy does not cover.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah, it the primary would just cover that correct?
[AGENT][NEUTRAL] Um, you would have to speak with them regarding that. Uh, let's see, yes, because on this policy, there is no medi there, there are no, uh, if I can get this out, there are no benefits for medication under this policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, OK, um, and then for the carve out list it would be the same though, um, you just follow whatever the primary.
[AGENT][NEUTRAL] That is correct. Anything not covered by the primary would not be covered by this policy either.
[CUSTOMER][POSITIVE] OK perfect and then um.
[AGENT][NEUTRAL] Oh, [PII], are you still there?
[CUSTOMER][NEUTRAL] Oh, can you hear me?
[AGENT][NEUTRAL] Oh, I can now. If you said anything, no, I couldn't. It sounded like the call had dropped.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh, yeah, just asking, um, again with the specialty pharmacy, um, if we don't buy a bill, um, again just following the primary guidelines.
[AGENT][NEGATIVE] But there are no benefits for medication on this policy.
[CUSTOMER][NEUTRAL] Right, yeah, and then um for prior authorization predetermination, um, that would not be required or optional correct because there's no medication benefits, OK.
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] No prior also on this supplemental policy.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] And then um so obviously then you're not seeing any prior uh predetermination on file correct?
[AGENT][NEUTRAL] Correct, because we would not do that.
[CUSTOMER][NEUTRAL] OK perfect. Alright, [PII], so just to recap with you then based off the information provided, um, uh, let's see this is a supplemental to the primary um it has office treatment writer once claims are approved and you did provide that website, um, benefits are up to the $5000 per calendar year.
[AGENT][NEUTRAL] For covered outpatient services. Mhm. Just for covered up services. Uh-huh.
[CUSTOMER][NEUTRAL] Um, but there are no medication.
[CUSTOMER][NEUTRAL] Yes, um.
[CUSTOMER][POSITIVE] Perfect.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And um for buying bill and carve out and specialty pharmacy you just follow the primary guidelines um and then uh there's no prior authorization required no.
[AGENT][NEGATIVE] If there are no benefits.
[AGENT][NEUTRAL] Correct. There are no benefits for, correct. Mhm.
[CUSTOMER][NEGATIVE] Right, uh, no, no.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then for prior authorization predetermination that would not be required or optional because there's no medication benefits because of the primary because you're secondary.
[CUSTOMER][NEUTRAL] All right, um, if all of that is correct, do you have a call reference number today?
[AGENT][NEUTRAL] Yes, you would use my name along with today's date.
[CUSTOMER][POSITIVE] All right, perfect. Well, [PII], thank you so much for your help today. You have a great rest of your day.
[AGENT][POSITIVE] Well, I hope you do too, and thank you again for calling APL Jeannette.
[CUSTOMER][POSITIVE] Thank you. Have a good one.
[AGENT][POSITIVE] You're welcome, you too, bye bye.