AccountId: 011433970860
ContactId: 03c3ca29-c3ba-434e-8332-bfd9b5c3be00
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1009500 ms
Total Talk Time (AGENT): 293278 ms
Total Talk Time (CUSTOMER): 293224 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/06/03c3ca29-c3ba-434e-8332-bfd9b5c3be00_20250106T16:22_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. I'm calling on behalf of the provider's office for eligibility and benefits on a recorded line. Help me with that, please.
[AGENT][POSITIVE] OK, I'll be more than happy to assist you with the eligibility and the benefits, and [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Mhm. Sure. My callback number is [PII].
[CUSTOMER][NEUTRAL] And for the policy number, please bear with me here. Let me just pull that up.
[AGENT][POSITIVE] Oh, sure, take your time.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK. So the policyholder here number's ID is 01836113.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Oh sure. The member's name here is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. I am showing the policy is active. It's been effective since [PII].
[CUSTOMER][POSITIVE] Mhm. Thank you very much. And can you please help me here with the group, uh, number, I mean group name?
[AGENT][NEUTRAL] So the group name is Universal Trucking.
[AGENT][NEUTRAL] And I'll spell the rest because I don't know if this is a word or abbreviation. It's H as in Harry, E as in elephant, N like Nancy, I like indigo, F like Frank, F like Frank.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. That is H E N I F F, right? Universal trucking. OK, one moment. Universal.
[AGENT][POSITIVE] Mhm. That's correct.
[CUSTOMER][NEUTRAL] Trucking is T R U C K A N G, right?
[AGENT][NEUTRAL] K I N G.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, got that. Thank you very much, [PII]. And uh may I have here the benefit period and the COP as well, please?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Wait a minute, can you have the, can you say that slowly, please?
[CUSTOMER][POSITIVE] Oh, sure, no problem. I'm so sorry about that. Like, um, may I know if the plan runs in the calendar year or physical year?
[AGENT][NEUTRAL] Yes, I got that part. What was the second part?
[CUSTOMER][NEUTRAL] Oh, so the second part is the COPD coordination of benefits.
[AGENT][NEUTRAL] Oh, coronation benefits, OK. So, um, the, the policy is on a calendar year, um, the max is $1500.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There is a $50 deductible per person up to $150 per family.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And there is no coordination of benefits, we'll process the claims, um, however it's received.
[CUSTOMER][NEUTRAL] OK, thank you very much. And is there any used amount from the 1500 here? And may I know if deductible met or not as well, please?
[AGENT][NEUTRAL] For [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][POSITIVE] Oh sure, no problem.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] So they have not met their deductible or used any of the max for this year yet.
[CUSTOMER][NEUTRAL] OK, thank you very much. And may I have you for the missing tooth cloth waiting period, and may I know if orthodontics is covered or not as well?
[AGENT][NEUTRAL] Orthodontic treatment is not covered. There is a twelve-month waiting period for major expenses, major for us includes endoonic, periodontic, prosodontic, and oral surgery, and there is a missing tooth cloth.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] OK. So 12 month waiting period for major services. There is a missing tooth cloth.
[CUSTOMER][NEUTRAL] OK, thank you very much for confirming. And can you please help me here with the percentages covered for diagnostic, preventative, basic, and major as well, please?
[AGENT][NEUTRAL] Preventative is covered at 100%, radiographs and FMX basic and basic restorative are all at 80%. Major expenses are at 40%.
[CUSTOMER][NEUTRAL] OK. So 80 is for basic and 40 is for major?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK, got that. Thank you very much once again. And do you downgrades and fillings and crowns?
[AGENT][NEUTRAL] Um, there's no downgrades.
[CUSTOMER][NEUTRAL] OK. And for crowns, may I know if they paid on the date of prep date? And may I have as well for crowns whether, uh, is it, I'm sorry, what, uh, may I have as well for crown dentist and bridges, the replacement period, please?
[AGENT][NEUTRAL] Once every 7 years, and what was the first question?
[CUSTOMER][NEUTRAL] OK. That was, uh, for Crohn's. Is it paid on the seat data prep date?
[AGENT][NEUTRAL] Oh, either or there's no specification.
[CUSTOMER][NEUTRAL] OK, no specification for that.
[CUSTOMER][NEUTRAL] OK. Thank you very much once again. And uh just to confirm, or endodontics, perdontics, or oral surgery is covered in the major 40%?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, thank you very much. And please help me confirm for implants and general anesthesia whether they are covered or not, please?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Implants, placement, removal, and all related services are not covered?
[AGENT][NEUTRAL] Um, anesthesia, I mean, it's not a separate benefit, but if there's oral surgery, it could be needed.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, can you help me confirm, uh, like, may I have the percentage is covered for uh general anesthesia?
[AGENT][NEUTRAL] If it's, there is no percentage specifically for anesthesia. If there's an oral surgery, it's 40%. It would depend on what type of benefit or what type of service the anesthesia is needed if it's basic, major, then you know the percentage.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][POSITIVE] OK, thank you very much for confirming. And uh
[CUSTOMER][NEUTRAL] OK. May I help you, please, uh, the percentages covered on the diagnostic for the services and the preventative, please?
[AGENT][NEUTRAL] I'm sorry, can you repeat that for me, please?
[CUSTOMER][NEUTRAL] Oh sure, no problem. They have the percentages covered and the frequencies for all the services and the diagnostic and preventative. Uh, what I mean to say it's like the percentages covered in the frequencies for periodic exam, FMX or panoramics, bite wings, prophylaxis or fluoride.
[AGENT][NEUTRAL] So panels
[AGENT][NEUTRAL] Panels and cleanings are once every 6 months?
[AGENT][NEUTRAL] Exams are 2 for 12 month period.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Bite wings are once per 12-month period.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Full mouth X-rays and panels are once every 5 years. Um, yeah, once every 5 years, yes. Crowns and bridges are once every 12 years per tooth, and partials and dentures are once every 5 years.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And what about fluoride and ceiling, are they covered?
[AGENT][NEUTRAL] Fluoride and fluoride and sealants are covered under preventative.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I mean, the it.
[AGENT][NEUTRAL] It's for an adult. So let me see, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For fluoride is limited to dependent children aged [PII] and max of 1 procedure per 12 months.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And let me see for the ceiling.
[AGENT][NEUTRAL] Sealant is maximum of 1 procedure per 12-month period.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] What else was see hold on one second.
[CUSTOMER][POSITIVE] Oh, sure, no problem.
[AGENT][NEUTRAL] Applications made to permanent molar teeth only.
[AGENT][NEUTRAL] Eliminate dependent children.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hold on.
[AGENT][NEUTRAL] Limited to dependent children under age [PII].
[CUSTOMER][NEUTRAL] OK, got that. Thank you very much for confirming. And uh may I have you, please, the percentages covered in the frequencies as well for SRP for multi department, or rein and power maintenance as well, please?
[AGENT][NEUTRAL] Do you have codes?
[CUSTOMER][POSITIVE] Oh yes, I do. I'm sorry about that.
[CUSTOMER][NEUTRAL] OK, so the code for SRP is 4341.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 434355
[CUSTOMER][NEUTRAL] 4381.
[CUSTOMER][NEUTRAL] 4910.
[CUSTOMER][NEUTRAL] 5670.
[CUSTOMER][NEUTRAL] 5751
[CUSTOMER][NEUTRAL] 7953
[CUSTOMER][NEUTRAL] 9310.
[CUSTOMER][NEUTRAL] 9944.
[CUSTOMER][NEUTRAL] 0367.
[CUSTOMER][NEUTRAL] And the last one is 0431.
[AGENT][NEUTRAL] OK, hold on one moment while I look through these codes for you, OK?
[CUSTOMER][POSITIVE] Oh, sure, mhm, mhm, sure, no problem.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] For
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So for 4341.
[CUSTOMER][POSITIVE] It's OK, no problem.
[AGENT][NEUTRAL] And 4 355, they're both um under major at 80% with a frequency of maximum 1 each quadrant per 24 months.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 4381 is major, 80%, no frequency.
[AGENT][NEUTRAL] 4910 is major with a maximum of 1 procedure per 6 months.
[CUSTOMER][NEUTRAL] Mhm. So for me it's covered at 80%.
[AGENT][NEUTRAL] This
[AGENT][NEUTRAL] I'm sorry, major is 40%.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, code 5670, um, major at 40% and maximum of 1 per 5-year period.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 5751 is major.
[AGENT][NEUTRAL] Maximum of 1 procedure per 24 months.
[AGENT][NEUTRAL] And 6 months.
[AGENT][NEGATIVE] Must have passed since initial placement.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 7953 is not covered.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 9310 is basic with no frequency.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] The other three codes are not covered.
[CUSTOMER][NEUTRAL] OK. Thank you so very much for all those information. And uh can you please help me double check, double check for, I'm sorry, double-check for 4341. May I know here for the SRP whether it's allowed to do only two quads per visit or all four quadrants?
[AGENT][NEUTRAL] It's not specified. It just says a maximum 1 quadrant per 24 months.
[CUSTOMER][NEUTRAL] OK, got that. Thank you very much once again for all those information. And just to confirm, uh, deductible here is only applies for the services and the basic and media, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. And may I know for the FMX and panoramics, whether they share frequencies or not, please?
[AGENT][NEUTRAL] Um, hold on one moment. Do you have a code? I don't, uh, FMX and panels. Hold on one second.
[AGENT][NEUTRAL] Do you have a code for that because it's a, it's a huge list, so I don't.
[AGENT][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hello, [PII].
[AGENT][NEGATIVE] Disconnecting call due to no response.