AccountId: 011433970860
ContactId: bfd85fbe-7862-48df-b1bd-d87e87264f12
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 435570 ms
Total Talk Time (AGENT): 136393 ms
Total Talk Time (CUSTOMER): 187772 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/03/bfd85fbe-7862-48df-b1bd-d87e87264f12_20250203T16:42_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] My apologies, I didn't catch your name.
[AGENT][NEUTRAL] My name is [PII]
[CUSTOMER][NEUTRAL] Hi, so, my name is [PII]. That's [PII] First initial of my last name is [PII], and I am calling from Test buyer together on a recorded line for quality assurance purposes at the request of Dr. [PII]'s office to verify benefits and eligibility information for a member by the name of [PII]. Is that something you can help with?
[AGENT][POSITIVE] Yes, I can assist you with eligibility, Mr. And may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII] extension of [PII] um so can I have the first initial of your last name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome, Miss [PII]. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] I have that listed as 01792121.
[AGENT][NEUTRAL] OK, thank you, one moment.
[AGENT][NEUTRAL] And you said you're calling from the office of Lauren Jones?
[CUSTOMER][NEUTRAL] At the request of the provider's office, yes ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] It will be [PII] and date of birth is [PII].
[AGENT][POSITIVE] OK. Thank you.
[AGENT][NEUTRAL] All right, and we have an effective date of [PII].
[AGENT][NEUTRAL] It is active at the moment and this is one of our secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] Alrighty, so I have effective, uh, [PII] secondary plan. Does it run on a calendar year?
[AGENT][NEUTRAL] It depends on the benefits and you said this is for an office. Let me see the benefits for office and this is not a guarantee of payment, just a verification of coverage and that's the disclaimer.
[AGENT][NEUTRAL] OK, with this one, we do not cover the office visits. Office visits are not covered. We only cover office procedures or treatments.
[AGENT][NEUTRAL] And that is subject to the outpatient maximum which is $5000 per year.
[CUSTOMER][NEUTRAL] OK, before we get into that, I just need a little bit of clarity. Well, actually, let's just, uh, continue on with the plan information first. uh, before we get into that, I do wanna go ahead and confirm what is the name of the plan?
[AGENT][NEUTRAL] This is a secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] With your medical.
[CUSTOMER][NEUTRAL] Alrighty and then for this members plan I do have a group number for billing purposes of 23633.
[AGENT][NEUTRAL] 2363, that is correct.
[CUSTOMER][NEUTRAL] have this as a commercial plan with a group name of Oklahoma Allergy and asthma clinic.
[AGENT][NEUTRAL] One moment, let me pull up.
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] OK, and what is the plan type?
[AGENT][NEUTRAL] OK, when you say plant type, what do you mean?
[CUSTOMER][NEUTRAL] Like what network does it run on like a PPO, EPO, HMO?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Commercial. There's no PPO or HMO. We follow primary, we're just a secondary.
[CUSTOMER][NEUTRAL] Alrighty, and I do wanna confirm is the provider in network with the members plan?
[AGENT][NEUTRAL] There's no network.
[AGENT][NEUTRAL] We're secondary, we follow a primary.
[CUSTOMER][NEGATIVE] No network.
[CUSTOMER][NEUTRAL] I can make another another network.
[CUSTOMER][NEUTRAL] Alrighty, so the benefits I would like to pay today are going to be for pre excuse me, test by a prefill syringe. However, it is done in a medical doctor's office, and I do have CPT code and administration code and diagnosis code. You did say that uh providers office uh or pro or office visits would not be covered. However, these benefits are not going to be billed with an office visit.
[AGENT][NEUTRAL] OK, that will be considered under the office treatment right.
[CUSTOMER][NEUTRAL] My apologies. I didn't catch all of that.
[AGENT][NEUTRAL] It will be considered under the office treatment rider.
[CUSTOMER][NEGATIVE] So it still would not be covered under this plan.
[AGENT][NEUTRAL] Again, it's gonna be considered under the office treatment rider. The only thing we do not cover is the office visit.
[CUSTOMER][NEUTRAL] OK, well, I would like to go ahead and provide those codes for you today.
[AGENT][NEUTRAL] We cannot pull back codes. Um, I can only give you general information about the benefits because we cannot quote anything we don't process claims over the phone.
[CUSTOMER][NEUTRAL] OK, you did say the member has a $5000 out of pocket max, correct?
[AGENT][NEUTRAL] Calendar year maximum, calendar year maximum, not out of pocket but calendar year maximum.
[CUSTOMER][NEUTRAL] Can
[CUSTOMER][NEUTRAL] Calendar year maximum. Anything been accumulated?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] As of today, they have not used their benefits, so the 4 month deal available.
[CUSTOMER][NEUTRAL] OK, in regards to this plan, uh, follows the member's primary plan, so no prior authorization would be required?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Thank you, thank you so much for all of that information that's actually everything that I need from you here today. Are you able to provide a reference number for today's call?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] We don't have a reference numbers. You can use my name in today's date.
[CUSTOMER][NEUTRAL] OK, and actually I actually do have one more question. My apologies. May the provider bind bill?
[AGENT][NEUTRAL] Yes
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Right, I may not buy in bill alrighty so specialty pharmacy would be mandatory, correct?
[AGENT][NEUTRAL] And we don't cover pharmacy.
[CUSTOMER][NEUTRAL] So the provider is not able to buy and build and the specialty pharmacy is not covered.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Are we able to double check that? So how would the uh medication be obtained?
[AGENT][NEUTRAL] For we cover for the administration.
[AGENT][NEGATIVE] You do not cover for the medicine.
[CUSTOMER][POSITIVE] Alright, thank you so much for that. That's actually everything. Hope you enjoy the rest of your day. Take care.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] You're welcome and thank you for calling APR. Have a good day, Mr.