AccountId: 011433970860
ContactId: 952487c1-2a57-4e13-8967-90a72378d195
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 544049 ms
Total Talk Time (AGENT): 199360 ms
Total Talk Time (CUSTOMER): 185194 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/14/952487c1-2a57-4e13-8967-90a72378d195_20250214T20:29_UTC.wav
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[AGENT][NEUTRAL] APL, this is [PII]. How may I help you?
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. Initial to my last name is [PII], calling on a recorded line, just needing to verify benefits for a patient coming into the office for infusion therapy, and I'm just needing to verify um specific CPT codes.
[AGENT][NEUTRAL] There's a therapy being done?
[CUSTOMER][NEUTRAL] Um, it's for Doctor [PII] come out at uh West County Rheumatology.
[AGENT][NEUTRAL] OK, so was it being done in a physician's office, outpatient hospital, infusion center?
[CUSTOMER][NEUTRAL] Physician's office.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what's the policy number, [PII]?
[CUSTOMER][NEUTRAL] Um, it's 02265958.
[AGENT][POSITIVE] And a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, it's a direct line it's [PII].
[AGENT][NEUTRAL] Can you repeat the, the three middle digits for me? [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] [PII]. OK, thank you.
[AGENT][NEUTRAL] And what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it's [PII]. Date of birth [PII].
[AGENT][NEUTRAL] OK, thank you. One moment.
[AGENT][NEUTRAL] Yeah
[AGENT][POSITIVE] So I am showing an effective date.
[AGENT][NEUTRAL] Of [PII].
[AGENT][NEUTRAL] Showing this policy is active at this time.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what is the infusion for?
[CUSTOMER][NEUTRAL] Um, infusion therapy, the diagnosis is rheumatoid arthritis.
[AGENT][NEUTRAL] OK. All right.
[AGENT][NEUTRAL] And so this policy does have a treatment writer under the policy.
[AGENT][NEUTRAL] Which means that covered items can be considered under the outpatient benefit which is up to $8100 I'm sorry, $8150 and that is per calendar year.
[AGENT][NEUTRAL] And information provided is verification, not a guarantee of payment?
[AGENT][NEUTRAL] And I do not see any claims used.
[AGENT][NEUTRAL] Any of that benefit used?
[AGENT][NEUTRAL] Um, yeah, I show, uh, we paid out.
[CUSTOMER][NEUTRAL] And do you take, oh.
[CUSTOMER][NEUTRAL] I'm sorry, um, do you take, uh, CPT codes to verify the benefits?
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] No, not necessarily. We just base it, you know, off of the location, um, and if it's for that diagnosis.
[CUSTOMER][NEUTRAL] OK, I'll
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][POSITIVE] OK perfect well then I will let you know um.
[AGENT][NEGATIVE] Of course we can't
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm so sorry, um, the medication is Orencia, um, and I also do just wanna let you know that this is not gonna be related to cancer. Um, it's gonna take place, like I said in the specialist office, um, the place of service is [PII], but it, it's just not gonna be billed as an office visit, it's gonna be billed professionally.
[AGENT][NEUTRAL] And so it's filled with treatment codes?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Is it treatment codes?
[AGENT][NEUTRAL] Injection codes, OK, of course, again, I can't guarantee anything, um, we won't know we'll need the claim to review it and so that's why I quoted the disclaimer.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] All right, um, is there a deductible or co-insurance or co-pay with these benefits?
[AGENT][NEUTRAL] No, this policy, it's a Metlink policy. It's secondary to the major medical plan. Um, it'll assist with deductible, co-insurance and or co-pay amounts of cover charges up to the benefit amount provided earlier.
[CUSTOMER][POSITIVE] OK perfect.
[CUSTOMER][NEUTRAL] Um, so it's gonna be covered at 100% currently.
[AGENT][NEUTRAL] Up to $8150.
[AGENT][NEUTRAL] And it depends on what amounts are applied towards those three categories up to 100%.
[AGENT][NEUTRAL] Of covered items.
[CUSTOMER][NEUTRAL] OK, and then.
[CUSTOMER][POSITIVE] Perfect. And can we buy and build the drug under the medical benefit?
[AGENT][NEUTRAL] No. No.
[CUSTOMER][NEUTRAL] OK, um, is there a carveout list of drugs not allowed under the medical benefit, or do you just normally verify that with the, OK.
[AGENT][NEUTRAL] There is not
[AGENT][NEUTRAL] Yeah, it there's not a carve out list.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEGATIVE] Maybe for the primary but not this one, no.
[CUSTOMER][NEUTRAL] Uh, since we cannot buy and build.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, if we decide not to buy a bill, is there a preferred specialty pharmacy?
[AGENT][NEUTRAL] And so the pharmacy for this employee, it should be on their identification. Well, actually there is no pharmacy benefit under this policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So there's no medical benefit and no pharmacy benefit?
[AGENT][NEUTRAL] OK, I'm providing you with the medical benefit. There is no pharmacy benefit.
[CUSTOMER][NEUTRAL] But you said that we cannot buy a bill, so therefore, there's no medical benefit for that medication.
[AGENT][NEUTRAL] Well then I guess I'm a little confused.
[AGENT][NEUTRAL] So you said that the inject, mhm.
[CUSTOMER][NEUTRAL] Uh, so for buying bill.
[CUSTOMER][NEUTRAL] Mhm, sorry, go ahead.
[AGENT][NEUTRAL] No, go ahead.
[CUSTOMER][NEUTRAL] Um, so for buy and bill, um, that's, um, that's the medical benefit. If, if you're saying we cannot buy and bill the medication, um, then, then you're saying that there's no medical benefit for the drug.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That's not what I said but I mean if if that's how you're looking at it I mean I can't go back and forth with you, so we do not buy and bill.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] And um.
[CUSTOMER][NEUTRAL] Is prior authorization required for this medication?
[AGENT][NEUTRAL] It's not required.
[CUSTOMER][NEUTRAL] Is predetermination required for the medication?
[AGENT][NEUTRAL] And we're not covering the medication. It's just the treatment, the injections.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, [PII], um, so just to recap with you based off the information provided, um, this plan is showing as secondary you verified that original effective date, um, currently covered at 100% because there's no deductible, co-insurance, or co-pay, cannot buy a bill, no carve out list, no specialty pharmacy, um, prior authorization is not required, nor would predetermination be required, um, because there is no medical benefits. Um, if all of that is correct, do you have a call reference number today?
[AGENT][NEUTRAL] Um, there's one thing that you missed. The benefit is up to the outpatient benefit is up to $8150 per calendar year, and the reimbursement is contingent upon how the primary insurance processes their claim. Have you verified benefits with the primary insurance?
[CUSTOMER][NEUTRAL] Um, not just yet.
[AGENT][NEUTRAL] Yeah, so this policy is secondary and 2nd position. And so if the primary does not cover it, if they deny it, it's not covered, this policy will not cover it either.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right, and is the primary the United plan?
[AGENT][NEUTRAL] I'll check to see if we have that information, but of course you'll need to check with the patient as well. One moment.
[CUSTOMER][NEUTRAL] Of course mhm.
[AGENT][NEUTRAL] I show you HC.
[CUSTOMER][POSITIVE] Perfect. Alright, [PII], do you have a call reference number for today?
[AGENT][NEUTRAL] Mhm. You'll use my name in today's state as your reference [PII] First initial last name is [PII].
[CUSTOMER][POSITIVE] All right perfect well thank you so much for your help today you have a great rest of your day.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL.