AccountId: 011433970860
ContactId: 933cf2a4-1809-4cca-8b85-e12614a566ec
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 849090 ms
Total Talk Time (AGENT): 232607 ms
Total Talk Time (CUSTOMER): 232992 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/933cf2a4-1809-4cca-8b85-e12614a566ec_20250121T15:20_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] Hi [PII], my name is [PII] calling on a recorded line. I just needing to verify benefits for a patient coming into the office for infusion therapy, and I just have specific CPT codes to verify.
[AGENT][NEUTRAL] OK, um, our policies don't really go by CPT codes, but I can help you with the benefits. And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yes, um, my number is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, it's 021-233-77 M as in Mary, L as in Lima 8.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Thank you, 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].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what type of benefits did you wanna um go over today? Were they like outpatient or inpatient?
[CUSTOMER][NEUTRAL] Yeah, um, since you don't take codes, I will just say the medication is Prolia. Um, this is not related to cancer. It is gonna take place in the office. The place of service is 11, um, and it's not gonna be billed as an office visit. It's gonna be billed professionally.
[AGENT][NEUTRAL] So is this like a procedure in an outpatient facility, hospital facility?
[CUSTOMER][NEUTRAL] It's outpatient in the office.
[AGENT][NEUTRAL] OK, so they have the office treatment rider in which the treatment in the office would be covered, but like you mentioned, it would be billed as a facility. Um, they don't have any in-office coverage in terms of place of service or facility, only the treatment in the office, and that would be paid up to $2000 per calendar year they have to go towards those expenses.
[CUSTOMER][NEUTRAL] OK, um, and is that the deductible?
[AGENT][NEUTRAL] No, the $2000 is the calendar year max that the policy will pay out on outpatient expenses.
[CUSTOMER][NEUTRAL] OK, is that the out of pocket then or is it just calendar max?
[AGENT][NEUTRAL] No, so this is their secondary insurance.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So there's no like out of pocket, it's primary um charges them like uh out of pocket like a co-pay or deductible. We help pay that, but we don't apply it. This, they have that 2000 to use to help pay those.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, so the benefit max is $2000 is that for individual?
[AGENT][NEUTRAL] As it like is it per person, yes.
[CUSTOMER][NEUTRAL] OK, is there a family as well?
[AGENT][NEUTRAL] Um, hold on one moment.
[AGENT][NEUTRAL] Um, no, it just says 2000 per covered. It's a couple policy.
[CUSTOMER][POSITIVE] OK perfect.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK perfect so this is a gap plan correct?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Alright, and has anything been accumulated so far with that calendar mac?
[AGENT][NEUTRAL] Let's see, hold on one moment.
[AGENT][NEUTRAL] Um, so far, no, they have not used any of the benefits for [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, and let me see here.
[CUSTOMER][NEUTRAL] And can we buy and build the drug under the medical benefit?
[AGENT][NEUTRAL] Um, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And for buying bill, do you mind if I place you on just a brief hold? I just need to look into that.
[CUSTOMER][POSITIVE] Yes, no problem.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] So
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes, I'm here.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. Um, so with the buying bill, so for the um medication, our policies don't cover the medication, we only cover the administration of it, which goes to the where it's being administered. So we don't um really do the buying bill because we don't cover the medication.
[CUSTOMER][NEUTRAL] OK, so that would be a no for buying bill. Um, is there a carve out list of drugs that are not allowed under the medical plan?
[AGENT][NEUTRAL] No, because we don't cover the drugs.
[CUSTOMER][NEUTRAL] Right. OK.
[CUSTOMER][NEUTRAL] OK, and um, is there a preferred specialty pharmacy if we don't buy a bill since we can't buy it.
[AGENT][NEUTRAL] Well, so anything with the medication, we wouldn't deal with. We are just, once we get the claim, we'll see where the um procedure was done in terms of the facility, and then we, we pay out on the claim. So we don't do anything with the medication.
[CUSTOMER][NEUTRAL] OK, um, so you would just follow the primary plan guidelines?
[AGENT][NEUTRAL] Right, we pay towards the copay, deductible and co-insurance after primary.
[AGENT][NEUTRAL] Now, primary you have to do all that, but not the secondary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK and then um it's prior authorization, I guess that would not be required.
[AGENT][NEUTRAL] Right, prior office is not required um because we're not the major medical.
[CUSTOMER][NEUTRAL] OK and then so predetermination is not required or optional as well?
[AGENT][NEUTRAL] Um, predetermination, well, wait, this is medical, so no, predetermination that's not required.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] And then um you said that you are secondary, correct?
[AGENT][NEUTRAL] Yes, we are.
[CUSTOMER][NEUTRAL] And is Medicare primary?
[AGENT][NEUTRAL] Um, no, not to our policy. Hold on one moment. Let me go to there.
[AGENT][NEUTRAL] Hold on one second. So we're primary to United Healthcare.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK perfect.
[CUSTOMER][NEUTRAL] And um is this fully funded or self funded?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hold on one second.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] OK, so fully funded.
[CUSTOMER][NEUTRAL] Perfect, um, and so it does follow the health plan guidelines for the primary?
[AGENT][NEUTRAL] Well, we have our own policy um benefits, but we we're just second to their primary. We don't.
[AGENT][NEUTRAL] Our policies are intertwined.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so you follow your own health plan guidelines?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, and a PCP referral is that required?
[AGENT][NEUTRAL] No, not for the secondary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, this is a gap plan and I have that um employer group name as um Orient Latin America.
[AGENT][NEUTRAL] Yes, that's correct. Um, did you need the group number?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] Alright, so it's 25037.
[CUSTOMER][POSITIVE] Perfect. And what is the claims address?
[AGENT][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[AGENT][NEUTRAL] 24.
[CUSTOMER][NEUTRAL] Alright perfect and is there a payer EDI number?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Uh, is that the same as the payer ID?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It's 60801.
[CUSTOMER][NEUTRAL] Perfect. Alright, [PII], um, so then just to recap with you based off the um information provided services are gonna be covered at 100% of the contracted rate, um, not exceeding the $2000 of the.
[CUSTOMER][NEUTRAL] Uh, benefit
[CUSTOMER][NEUTRAL] Snacks and nothing's been used um we cannot buy and bill. There is no carve out list um no specialty pharmacies and um this follows the primary guidelines no prior authorization predetermination or optional predetermination, um, secondary to United, um, we are showing, are we showing as in network?
[AGENT][NEUTRAL] Um, the secondary doesn't have a network.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] And then, uh, you verify the patient's original effective dates, the calendar year fully funded, follows health plan guidelines. PCP referral is not required. It's a gap commercial plan. Verify that group name, group number, and the claims address and payer ID number. If all of that is correct, do you have a call reference number today?
[AGENT][POSITIVE] Yep, that's correct.
[AGENT][NEUTRAL] Um, there's no call reference number, but you can use my name, which is [PII], and then today's date.
[CUSTOMER][POSITIVE] All right perfect well thank you so much for your help today you have a great rest of your day.
[AGENT][POSITIVE] Thank you, you also, and thanks for calling APL. Bye-bye.
[CUSTOMER][POSITIVE] Thank you, bye.