AccountId: 011433970860
ContactId: c45838e9-23b9-43ed-ba42-3a6283054e36
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 515299 ms
Total Talk Time (AGENT): 158701 ms
Total Talk Time (CUSTOMER): 264200 ms
Interruptions: 5
Overall Sentiment: AGENT=0.8, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/18/c45838e9-23b9-43ed-ba42-3a6283054e36_20250218T21:07_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. It's [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling on a recorded line, just needing to verify benefits for a patient coming into the office for infusion therapy, um, and then just have specific CPT codes to verify.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I can verify benefits for you and your name is again? I can barely hear you.
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] OK, and Mrs. [PII], what is the policy number, please?
[CUSTOMER][NEUTRAL] 01792121
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] Uh, it sounds like it's missing the number. Can you give that to me one more time? Oh, I think I probably do. What's the patient's name, date of birth? Sorry.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's [PII] [PII].
[AGENT][NEUTRAL] OK, and do you have a callback number in case the call drops?
[CUSTOMER][POSITIVE] Pro.
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][NEUTRAL] OK, and I'm showing his effective date is [PII]. He is active on the policy. And you say you're calling to verify benefits?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and is this services performed outpatient or in hospital?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Outpatient.
[AGENT][NEUTRAL] OK, not a guarantee of payment, just a verification of coverage. With this policy, we are secondary. We have with primary insurance deductible, co-pay, and or co-insurance, and I show you as a benefit max up to $5000 per calendar year.
[CUSTOMER][NEUTRAL] What.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. And has anything been accumulated to that max?
[CUSTOMER][NEUTRAL] that
[AGENT][NEUTRAL] Um, let's see one moment.
[AGENT][NEUTRAL] Uh, no, ma'am. I don't show any benefits have been used, so it's still available.
[CUSTOMER][NEUTRAL] And you said $5000?
[AGENT][NEUTRAL] Uh, yes, they have a benefit max up to 5000 per calendar year.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] And uh for buying bill, would you just follow the primary guidelines?
[AGENT][NEUTRAL] Well, we just pick up what uh primary applies towards deductible, co-pay or co-insurance. We don't have any control as far as any buy and billing.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and then is there a carve-out list or illicit drugs not allowed under the medical benefit, or again, do you just follow what the plan does?
[AGENT][NEUTRAL] Uh, we don't have a list of prescription that is covered or not.
[CUSTOMER][NEUTRAL] And this is a gap plan correct?
[AGENT][NEUTRAL] Uh, it's a secondary supplemental policy.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] And um it, so you said that buying bill is not an option.
[AGENT][NEUTRAL] Oh, we don't have any control over that. It's something I guess you would have to contact the primary, but we only pick up what they apply towards deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh right, so, so you follow the primary guidelines you do with the primary plan.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] One, right. OK. Yeah. Um, and so then you wouldn't have a specialty pharmacy, you would just follow the primary guidelines on what specialty pharmacy they would say.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] That
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] And is the primary the, the anthem policy? Are you able to see that?
[AGENT][NEUTRAL] No, ma'am. That's something you have to contact the patient. It'll be whoever their primary is through their employer.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] And um,
[CUSTOMER][NEUTRAL] For prior authorization, um, is that required for that medication? Um, I can give you that information.
[AGENT][NEUTRAL] No, ma'am, it's not required.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK. And, and since you don't take codes, um, I will just give you a description. The medication is test fire. Um, this is not related to cancer and it will take place in the specialist office and the place of service is [PII], but it's just not gonna be billed as an office visit. It would be billed professionally.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just to let you be aware of that and then for predetermination that would also not be required, correct or optional.
[AGENT][POSITIVE] Uh, correct.
[CUSTOMER][NEUTRAL] And so you're not able to see if there is a predetermination or prior off on file.
[AGENT][NEUTRAL] We don't have a prior authorization or check for pre-determination.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. And then, what is the patient's original effective date?
[AGENT][NEUTRAL] Uh, effective date is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That makes more sense and this is run through a calendar year.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And is this fully funded or self funded?
[AGENT][NEUTRAL] Um, assume it's [PII] who he's the employer.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And it follows the health plan guidelines.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] For American public.
[CUSTOMER][NEUTRAL] And is a PCP referral required?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK and this is a commercial PPO.
[AGENT][POSITIVE] commercial, correct.
[CUSTOMER][NEUTRAL] Yeah, it's for billing purposes, can you verify the group name and group number?
[AGENT][NEUTRAL] Uh, yes, group name is Oklahoma Allergy and asthma clinic.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And the group number is 23633.
[CUSTOMER][NEUTRAL] And that was Oklahoma asthma clinic?
[AGENT][NEUTRAL] Oklahoma Allergy and Asthma Clinic is the group name.
[CUSTOMER][NEUTRAL] And is there a plan number or a coverage description?
[AGENT][NEUTRAL] It is a secondary supplemental policy.
[CUSTOMER][NEUTRAL] It.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK. And what is the claims address?
[AGENT][NEUTRAL] PO Box 248,950.
[AGENT][NEUTRAL] Oklahoma City, Oklahoma.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Alright, [PII], um, so just to recap with you, based off the information provided, um, benefits are gonna be up to the $5000 a year. You need to get doesn't, um, for buying bill car value specialty pharmacy, um, you would just follow whatever the primary guidelines are.
[CUSTOMER][NEUTRAL] And then prior authorization is not required, predetermination is not required or optional. We did not see any of the files. You're showing a secondary should not verify your primary insurance. We verified the patient's original effective date, the calendar year, fully funded, follow health plan guidelines. PCP referral is not required. We verified the the commercial PTO, the group name, number, plan description, and the claims address.
[CUSTOMER][NEUTRAL] If all of that is correct, do you have a call reference number today?
[AGENT][NEUTRAL] Uh, no, ma'am. We don't give reference numbers. If you like, you may use my name in today's date.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Alright, [PII], thank you so much for your help today. You have a great day.
[AGENT][POSITIVE] Oh, you too, Ms. [PII]. Thank you for calling APL. Bye.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] What.