AccountId: 011433970860
ContactId: ecff0b81-4c1a-44c1-a5c6-c8d403f9a075
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 462989 ms
Total Talk Time (AGENT): 146750 ms
Total Talk Time (CUSTOMER): 195226 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/17/ecff0b81-4c1a-44c1-a5c6-c8d403f9a075_20250417T20:05_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATM. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Um, hello. I'm sorry. I didn't catch your name. Can you hear me?
[AGENT][NEUTRAL] Yes, ma'am. I can hear you.
[CUSTOMER][NEUTRAL] Um, hello, my name is [PII], and I'm calling from the Lexia Service Center for the Lexio brand of Inlycerin on behalf of the Novartis Pharmaceuticals Corporation, and this call may be monitored or recorded for training, quality assurance, product development and improvement purposes. I am calling on behalf of Doctor [PII]. I need to verify the eligibility and benefits of one of your members.
[AGENT][POSITIVE] I'm sure [PII]. I can assist you with that. I first I contact number just in case we're disconnected.
[CUSTOMER][NEUTRAL] I am so sorry. It's a bad connection. I can hear you, but I can't make out what you're saying.
[AGENT][NEUTRAL] Let's see. Is this better?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. All right. Well, thank you, [PII]. Um, first I'll need a good callback number just in case we disconnected.
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] OK, thank you. Now, I need the member's policy number.
[CUSTOMER][NEUTRAL] Is 01854360 ML 8.
[AGENT][NEUTRAL] Can I please verify the patient's name and date of birth?
[CUSTOMER][NEUTRAL] It is [PII]. The date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. I just that verification coverage does not guarantee payment of claims.
[AGENT][NEUTRAL] And the effective date on this policy was [PII]. The policy is still active.
[AGENT][NEUTRAL] And is this for inpatient or outpatient benefits for an office visit?
[CUSTOMER][NEUTRAL] I'm sorry. I'm so sorry. I, did you say [PII]?
[AGENT][NEUTRAL] Yes, ma'am. That's when the policy was affected.
[CUSTOMER][NEUTRAL] There's no termination date?
[AGENT][NEUTRAL] No, the policy is still active.
[CUSTOMER][NEUTRAL] And can you tell me what type of plan this is?
[AGENT][NEUTRAL] This is secondary gap insurance.
[CUSTOMER][NEUTRAL] OK. Secondary gap.
[CUSTOMER][NEUTRAL] And would it be considered a Medicare or commercial plan?
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. Is it a PPO HMO?
[AGENT][NEUTRAL] Ma
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And for billing purposes, is there a group name and a group number?
[AGENT][NEUTRAL] And yes, the group number is.
[AGENT][NEUTRAL] 16701.
[CUSTOMER][NEUTRAL] You said 16701.
[AGENT][NEUTRAL] Yes, ma'am. That's the group number.
[CUSTOMER][NEUTRAL] Is there a group name?
[AGENT][NEUTRAL] Yes, the group name is Integrated Bank.
[CUSTOMER][NEUTRAL] Incredit Bank.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, hold on one second.
[CUSTOMER][NEUTRAL] Um, can you tell me if, uh, this is showing the member's secondary plan, right?
[AGENT][NEUTRAL] Yes, it is.
[CUSTOMER][NEUTRAL] And are you able to tell me if the provider and if the facility is in network with the member's plan? I do have an MPI for both of them.
[AGENT][NEUTRAL] There is no network because we go by the primary insurance carrier's guidelines.
[CUSTOMER][NEUTRAL] OK, no network.
[CUSTOMER][NEUTRAL] And now I have 3 codes. I have a J code, a CPT code, and a diagnosis code. I'm requesting benefits.
[AGENT][NEUTRAL] Well, where would the services take place?
[CUSTOMER][NEUTRAL] Um, in the specialist office.
[AGENT][NEUTRAL] OK, for services provided in office?
[AGENT][NEUTRAL] We cover up to 1500 per calendar year.
[AGENT][NEUTRAL] And that's for the co-insurance and the deductible after the primary insurance process is decline.
[CUSTOMER][NEUTRAL] You, you will cover up to $1000 after the primary submits the claim.
[AGENT][NEUTRAL] We'll cover up to 1500 per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And so for, uh, and so on this plan there, you, you, um, there's no co-insurance, no deductible, no out of pocket. Y'all are just covered up to the 1500.
[AGENT][NEUTRAL] Right. After the primary insurance processes the claim, the charges that go towards the coinsurance and the deductible, we cover up to $1500 per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is a prior authorization required for um this plan uh for the J code?
[AGENT][NEUTRAL] No, ma'am, it isn't because again we go by the primary um insurance guideline.
[CUSTOMER][NEUTRAL] OK, so predetermination and prior authorization is not required and not available.
[AGENT][POSITIVE] That's correct. Because um at the time, mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, um, I was just gonna say I, I still have to say it for the QA, um, for the prior authorization. Um, are you able to see if there is a prior authorization currently on file?
[AGENT][NEUTRAL] No, ma'am, there isn't.
[CUSTOMER][NEUTRAL] OK. And then is step therapy required?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] And can the provider buy and bill?
[AGENT][NEUTRAL] Can be, yes, ma'am.
[CUSTOMER][NEUTRAL] And then specialty pharmacy, is it required or available?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] And then does the member have a site of care policy on their plan?
[AGENT][NEUTRAL] No, not that I'm aware of. No, ma'am.
[CUSTOMER][NEUTRAL] OK. All right. Now, can I have the spelling of your first name with the first initial to your last and a reference number for the call?
[AGENT][NEUTRAL] Yes, ma'am. The reference number is my name and today's date. My first name is spelled [PII]
[AGENT][NEUTRAL] And the last initial is [PII].
[AGENT][NEUTRAL] EN and today's d[PII], that's the reference number?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, is there anything else?
[CUSTOMER][POSITIVE] OK. [PII] OK. No, that is all. Thank you so much for your time, OK?
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, thank you, [PII] for calling ATL. You have a great day. Mm bye.
[CUSTOMER][POSITIVE] Alright, thanks, bye.