AccountId: 011433970860
ContactId: a8f398e2-afaa-48b7-a3b1-9a80f4e97a78
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 610340 ms
Total Talk Time (AGENT): 320309 ms
Total Talk Time (CUSTOMER): 258214 ms
Interruptions: 6
Overall Sentiment: AGENT=1.2, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/19/a8f398e2-afaa-48b7-a3b1-9a80f4e97a78_20250619T18:08_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. Last initial [PII], and I'm calling with Solio Health to um get some clarification on a patient's um benefits eligibility for her infusion therapy.
[AGENT][NEUTRAL] OK, so you're needing eligibility and benefit information, [PII], a member, is that correct?
[CUSTOMER][NEUTRAL] Yes. Yes. Mhm.
[AGENT][POSITIVE] Yes, I can help you with that and what is a good call back number for you please?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][POSITIVE] Thank you and the member's policy number please.
[CUSTOMER][NEUTRAL] That is going to be 02567750.
[AGENT][POSITIVE] OK, thank you one moment please.
[AGENT][NEUTRAL] And any information that I do provide for you today, [PII] would be a verification of benefits and not a guarantee of payment. What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient is [PII] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so I do show that she is the subscriber on the supplemental policy and it is active with an effective date of [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And so,
[AGENT][NEUTRAL] What kind of benefit question can I answer for you or try and give provide you information for?
[CUSTOMER][NEUTRAL] So, um, her referral to us was for an infusion therapy that will take place potentially at home or in one of our infusion suites. Does her, uh, supplemental policy cover that?
[AGENT][NEUTRAL] OK, so for her outpatient benefit, um, it's, she has a treatment writer, an office treatment writer.
[AGENT][NEUTRAL] That this could potentially be reviewed under but not for home.
[AGENT][NEUTRAL] Um, and the.
[AGENT][NEUTRAL] Benefit maximum on her policy.
[AGENT][NEUTRAL] Per calendar year is a combined for outpatient is $5000.
[AGENT][NEUTRAL] Give me one moment to pull up some additional information. The system's loading it kind of slowly for me, so let me try something different. One second.
[AGENT][NEUTRAL] OK, so yes, her outpatient benefit maximum per calendar year for covered outpatient services is $5000 and there is no outpatient deductible per cover person per calendar year.
[CUSTOMER][MIXED] OK, so there's no deductible, but there is like uh an max out of pocket of 5000.
[AGENT][NEUTRAL] That's the maximum benefit that this plan will pay.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Per calendar year for covered outpatient services so when the claim is submitted to APL for review, we will have to have a copy of her primary insurance company's explanation of benefits.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] As well.
[AGENT][NEUTRAL] And then once we've reviewed the claim here at APL [PII], we do have a portal that you should be able to check claim status in.
[AGENT][NEUTRAL] For her by going to [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, let's see, so the potential to be reviewed for the services that would happen at the time that we submit that claim with the primary.
[CUSTOMER][NEUTRAL] Um, claim information correct? am I understanding that correct?
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] Yes, we, we have to have you right, so the claim would be filed with our primary first and then with APL since we have to have a copy of the primary insurance company's explanation and benefits.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] OK and so and just to clarify, sorry.
[AGENT][NEUTRAL] Uh, no, you're fine.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So I, I know you stated that she would not be or not have coverage for like a home infusion therapy, but if she was to get it done in like our outpatient infusion clinic.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Like an office setting, correct, that that is.
[CUSTOMER][NEUTRAL] Yeah, well, yes, I guess it would still be tied to us or a home infusion provider, but we have like.
[CUSTOMER][NEUTRAL] Um, an outpatient infusion suite that patients can go to as well, um, I don't know how you guys classify that if it still would be under because our provider type is a home infusion provider if you guys would still classify that under home infusion.
[AGENT][NEUTRAL] OK, um, again we would just we'll have to receive the claim to see how it is actually billed and processed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For review.
[CUSTOMER][NEUTRAL] OK, um, OK, and one more question, sorry, um, so.
[AGENT][NEUTRAL] Sure, OK, you're fine.
[CUSTOMER][NEUTRAL] One of my other coworkers had called this morning in regards to benefits, same type of thing, uh, for this patient and she was told during those calls that um the patient's policy obviously doesn't cover home infusion it's only DME services.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is that correct?
[AGENT][NEUTRAL] Well, this, OK, say that all one more time.
[CUSTOMER][NEUTRAL] So co-worker was told this yeah.
[AGENT][NEUTRAL] It appeared that way, OK, the.
[AGENT][NEUTRAL] Uh-huh, go ahead.
[CUSTOMER][NEUTRAL] No, that's OK. So, um, my coworker called this morning and she was told that this patient's plan obviously doesn't cover home infusion, it only covers DME.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Uh, no, she was, according to the notes, she was told the same thing as I said to you about the office treatment writer on this plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And DME.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But does not cover and then and there, there's also a DME writer on here, but that does not cover home infusion.
[AGENT][NEUTRAL] I see that note.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] And gave this and gave her the.
[AGENT][POSITIVE] Maximum benefit, this which is the same as what I provided for you.
[CUSTOMER][NEUTRAL] OK, alright, perfect. I just, she's fairly new to all this, so I just wanted to call and and clarify, you know, because sometimes things can be lost in transition, so.
[AGENT][NEUTRAL] Uh-huh. No, I, no, that's OK. Yeah. It's over. Sure. Absolutely. I know, I totally understand. Yes. So, but that is correct. This policy does have a DME writer, but that's, you know, obviously doesn't cover disposables wise, but it doesn't cover for home health or, you know, the home infusion.
[CUSTOMER][NEUTRAL] But, all right.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, so the DME part of that is disposable supplies that's what you classified as non-covered DME.
[AGENT][NEUTRAL] Not disposable. It, well, not covered. Yeah, DME is covered under here. OK, let's get, let me do that again. Durable medical equipment is covered under the rider on this policy, but the definition of durable medical equipment means that it can withstand repeated use, is not disposable.
[CUSTOMER][NEUTRAL] OK. All right.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It is used to serve a medical purpose with respect to treatment of an inpatient cover charge or an outpatient cover charge.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] is applicable and is not useful to a person in the absence of sickness or injury. It's appropriate use for primarily used within, within the home. It is not implantable within the body and it is covered by the other medical plan.
[CUSTOMER][NEUTRAL] OK, so I think that the biggest thing is is we, we do have a supply code that we call like we would classify as DME um and so I think that's where part of the confusion was was well our supply code is considered DME.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But we didn't like I think what you just read kind of clarified that was that it's what's not covered under DME would be disposable supplies which.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] We're talking like alcohol pads for the infusion, stuff like that, stuff that's only gonna get used one time. Yeah.
[AGENT][NEUTRAL] Anything disposable is not covered, right? That's not covered. It has to be able to withstand repeated use and is not disposable.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][POSITIVE] OK perfect that that verifies everything um alright perfect and then it.
[AGENT][NEUTRAL] OK, and then just make sure.
[AGENT][NEUTRAL] Go ahead, [PII].
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] Oh, go ahead with your question.
[CUSTOMER][NEUTRAL] No, I was just gonna ask for a reference number if you had one.
[AGENT][NEUTRAL] Sure, you're gonna use my name, which again is [PII] along with today's date.
[AGENT][NEUTRAL] And then I did give you the portal website that you all should be able to check claim status in did I give you that [PII]?
[CUSTOMER][NEUTRAL] Mhm. You did, yes.
[AGENT][NEUTRAL] OK, I thought I did, but I just wanted to ask you one more time to make sure.
[CUSTOMER][POSITIVE] Right, been a long week. So, all right, well, I appreciate your help, [PII]. Thank you so much.
[AGENT][NEUTRAL] Ah, yes.
[AGENT][POSITIVE] Well, you're welcome. You are certainly very welcome and if that is all I can help you with for this moment anyway, thank you again for calling APL and I hope you have a wonderful rest of your day.
[CUSTOMER][POSITIVE] You as well thank you bye bye.
[AGENT][POSITIVE] All right, thanks, [PII]. Bye-bye.