AccountId: 011433970860
ContactId: 9c89e22a-eb2f-4ef4-a12b-51401995f8f7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 612440 ms
Total Talk Time (AGENT): 216508 ms
Total Talk Time (CUSTOMER): 206743 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=1.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/14/9c89e22a-eb2f-4ef4-a12b-51401995f8f7_20250214T21:00_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII] calling on a recorded line. Uh, 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, Ms. [PII], I can help you with benefits. Um, can I get your callback number just in case our call is disconnected?
[CUSTOMER][NEUTRAL] Of course it's [PII].
[AGENT][NEUTRAL] OK. And then what is the patient's name?
[CUSTOMER][NEUTRAL] Uh, the patient's name is [PII]. It's 6-15-1960.
[AGENT][NEUTRAL] And then what is the patient's, um, policy number?
[CUSTOMER][NEUTRAL] 02265958
[AGENT][NEUTRAL] OK, let me look that up real quick.
[AGENT][NEUTRAL] OK, I
[AGENT][NEUTRAL] Do show that this policy for [PII], I'm sorry, has lapsed, um, the policy was no longer active effective [PII].
[AGENT][NEUTRAL] I'm looking to see, she she does have an active policy now though. Let me give you that policy number.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's 255-6241.
[AGENT][NEUTRAL] And the effective date is [PII].
[CUSTOMER][POSITIVE] OK perfect thank you for that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this is just to verify her benefits. It's not a guarantee of payment. This is a supplemental insurance policy. It's billed secondary to the primary. It's a gap insurance that helps with deductible, co-pay and co-insurance only. She has an inpatient benefit amount of 8100.
[AGENT][NEUTRAL] $50 per calendar year and then she also has an outpatient benefit amount of $8150 per calendar year. I'll check to see if anything has been used this year for you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Nothing has been used so far in the year [PII].
[CUSTOMER][NEUTRAL] OK, so you said this is a Medicare supplemental plan?
[AGENT][NEUTRAL] It uh supplemental insurance that's secondary to her primary.
[AGENT][NEUTRAL] That helps with deductible copay and co-insurance.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] All right. um, and then, so as far as um buy and bill, would you just, uh, follow the primary guidelines?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And um is there a deductible co-insurance or co-pay um or is it just um going up to that 8150 per calendar year?
[AGENT][NEUTRAL] Um, as far as
[AGENT][NEUTRAL] It, it just goes up to that 8150 per calendar year.
[AGENT][NEUTRAL] Uh, and it helps with, with the deductible co-pay or co-insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and the buy and bill follows the primary guidelines, um, would that be the same for the carve out list that just follows the primary guidelines?
[AGENT][NEUTRAL] It files, it follows our guidelines per the patient's policy.
[AGENT][NEUTRAL] Now if it's not a covered procedure with the primary then it's not something that we would.
[AGENT][NEUTRAL] Cover.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, it's the, um, and it doesn't actually go by procedure. It goes by facility and
[CUSTOMER][NEUTRAL] Um, and then.
[AGENT][NEUTRAL] Deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] OK, is it OK if I give you a description even though you don't take the the CPT code?
[AGENT][NEUTRAL] It, what kind of facility is, is it going to be performed in?
[CUSTOMER][NEUTRAL] The specialist office.
[AGENT][NEUTRAL] OK, let me see if she has office visits on our policy.
[CUSTOMER][NEUTRAL] I will say, um, so it's gonna take place in the specialist office and the place of services 11 um but it's not going to be billed as an office visit. It's gonna be billed professionally, um, and the medication is Orencia, um, and it's not related to cancer.
[AGENT][NEUTRAL] We don't um pay for the medications, we just pay, just help with deductible, co-pay and co-insurance. Um, this insured can.
[AGENT][NEUTRAL] I'm gonna pull up her policy to see if she has office visits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's gonna be just a second why that policy.
[AGENT][POSITIVE] It pulls in for us so I can read it real quick.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, she does not have office visits on her policy.
[AGENT][NEUTRAL] It doesn't cover the office visit, but it helps with the physician's visit, the fee, the physician's fee.
[CUSTOMER][POSITIVE] OK, helps with this
[CUSTOMER][NEUTRAL] Let's see, OK.
[CUSTOMER][NEUTRAL] Um, and then is there a designated specialty pharmacy or would it just be whoever is in network?
[AGENT][NEUTRAL] Well, we don't do the um.
[AGENT][NEUTRAL] Pharmacy side of it. We don't do the um medication side of it. That would be under her primary insurance.
[CUSTOMER][POSITIVE] OK, great. Um.
[CUSTOMER][NEUTRAL] And then, um,
[CUSTOMER][NEUTRAL] Do you have um a network? Is there a provider network for this?
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, and um for prior authorization for the medication, um.
[CUSTOMER][NEUTRAL] Would there be prior um authorization would that be required?
[AGENT][NEUTRAL] No ma'am, because we're not the primary.
[CUSTOMER][NEUTRAL] Right, right, OK, um.
[CUSTOMER][POSITIVE] And perfect.
[AGENT][NEUTRAL] Miss [PII], what's the name of the facility you're calling from, please?
[CUSTOMER][NEUTRAL] West County rheumatology.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] And then perfect.
[CUSTOMER][NEUTRAL] And then what is the the patient's original effective date is [PII]. I just run through a calendar year?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, and is this self funded or fully funded?
[AGENT][NEUTRAL] It's self funded, it's it's.
[AGENT][NEUTRAL] It's a group insurance that's done through her employer that's payroll deducted.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] All right, [PII], um, so just to recap with you based off that information provided, um,
[CUSTOMER][NEUTRAL] See it's an active plan as of [PII], um.
[CUSTOMER][NEUTRAL] This, um, the supplemental plan, um, it goes up to the 8150, um, per calendar year follows the primary guidelines.
[CUSTOMER][NEUTRAL] Um, you don't pay for the medication. You pick up the deductible, co-insurance or co-pay. You don't have the office visits or policy helps with the physician fee, um, for buying bill and the carve out, you would just follow the primary guidelines, um, and prior authorization would not be required. Um, if all of that is correct, do you have a call reference number today?
[AGENT][NEUTRAL] Right. And
[AGENT][NEUTRAL] Oh, we don't follow the primary guidelines. We follow our policy.
[AGENT][NEUTRAL] The, the, how the policy is written for the insured.
[CUSTOMER][NEUTRAL] Oh, OK, OK.
[CUSTOMER][POSITIVE] Perfect. All right, um, and do you have a call reference number today?
[AGENT][NEUTRAL] Yes, ma'am. You can use my name, [PII], and today's date.
[CUSTOMER][POSITIVE] All right well thank you so much you have a great rest of your day.
[AGENT][POSITIVE] You too you have a good um [PII] too thanks for calling APL.
[CUSTOMER][POSITIVE] Oh you too thank you bye.
[AGENT][POSITIVE] Thank you.