AccountId: 011433970860
ContactId: 03e48811-3b47-402f-bbb5-33f14fe7ba19
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 434119 ms
Total Talk Time (AGENT): 161373 ms
Total Talk Time (CUSTOMER): 192860 ms
Interruptions: 3
Overall Sentiment: AGENT=1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/23/03e48811-3b47-402f-bbb5-33f14fe7ba19_20250523T15:45_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling on behalf of the dental office to check the eligibility and the benefit for the patient on a recorded line. Could you please help me with that?
[AGENT][NEUTRAL] Yes, I can check eligibility and benefits for you. I'm sorry, you said your name was [PII]?
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] OK, uh, can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's [PII], and it's a direct number.
[AGENT][NEUTRAL] OK, thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, the member ID is 02456777, 3 consecutive seven.
[AGENT][NEUTRAL] Got it. And then what was the name and date of birth for the member, please?
[CUSTOMER][NEUTRAL] Yes, the patient's name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you and then uh let's see.
[CUSTOMER][NEUTRAL] Are you.
[AGENT][NEUTRAL] Uh, this was for dental correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so this policy is active. Effective date was [PII], and if you'd like I can send you a fax box that shows all of the covered procedures and benefit information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I have a very specific question. um like benefits, I believe the policy runs in a calendar year plan with the standard coordination of benefit.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Uh, I want to know if provider is in network or not. So can I give the provided information to you?
[AGENT][NEUTRAL] So this policy participates in the Carrington PPO network. however, utilization of a provider within [PII] is not required, so this policy does not have to be in a specific network.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And the group name would be Creative Circle and the group number would be 70,030.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] And the payer mailing address is [PII] City, OK, [PII].
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Got it. Uh, please, uh, the plan max of the, it, it is a 500 of plan max and individual is 50, family is 150 deductible, and I believe nothing has been used in that.
[AGENT][NEUTRAL] Um, I can do that is, uh, that information is correct, but let me double check to make sure, um, I'll see if anything has been used. Give me just a moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, right, so none has been used so far this year and the deductible has not been met.
[CUSTOMER][NEGATIVE] And there's no other benefit for this patient orthodontics.
[AGENT][NEUTRAL] What was that? I'm sorry?
[CUSTOMER][NEUTRAL] No auto benefits, orthodontics?
[AGENT][NEUTRAL] Right. Orthodontic treatment is not covered.
[CUSTOMER][POSITIVE] And there's no missing tooth cloths and waiting period.
[AGENT][NEUTRAL] There is a missing tooth clause, uh, but no waiting period.
[CUSTOMER][NEUTRAL] OK, there is a missing class.
[CUSTOMER][NEUTRAL] Could you please help me with the coinsurance percentage for the 2 basic and major?
[AGENT][NEUTRAL] Um, so the coverage amount for, uh, there is no major coverage under this policy, uh, preventative is at 100%, radiographs, uh, FMX, and the basics are all going to be at 80%.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Andy wing is also 80%.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And periodic exam is 100%, 0120.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Oh, I apologize, um, bite wings, I'm so sorry, bite wings are actually under preventative, so that is 100%.
[CUSTOMER][NEUTRAL] And prophy fluoride.
[CUSTOMER][NEUTRAL] OK. And periodic exam is also 100%, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And fluoride insulins are not covered due to the age limit.
[AGENT][NEUTRAL] Uh, what was that procedure code?
[CUSTOMER][NEUTRAL] 1206 and 1351.
[CUSTOMER][NEUTRAL] Well
[AGENT][NEUTRAL] Right, OK, so 1351.
[AGENT][NEUTRAL] Is covered, but let me check that age limit. Give me just a moment.
[AGENT][NEUTRAL] OK, yeah, so limited to dependent children under [PII].
[CUSTOMER][NEGATIVE] Similarly, 120 6 also not covered.
[AGENT][NEUTRAL] 1206 is not covered.
[CUSTOMER][NEUTRAL] Got it. And there is no downgrade for purchase or composite 2393. And it is under 80%, right? And there is no end of payroll as well because, right?
[AGENT][POSITIVE] Correct. Correct.
[AGENT][NEUTRAL] There is no what I'm sorry.
[CUSTOMER][NEUTRAL] And and payroll services, androdontics and periodontics are also not covered.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. It's 9310. It's a covered services not or not. 9310.
[AGENT][NEUTRAL] 9310, yes, that is covered under basic and there are no limitations, so 80%.
[CUSTOMER][POSITIVE] No limitation means there is no frequency. It is as needed.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK, the FMX and panel, I believe they are frequency and the frequency would be 1 in 5 calendar year.
[AGENT][NEUTRAL] For a panel, you said, I'm sorry?
[AGENT][NEUTRAL] For not
[CUSTOMER][NEUTRAL] Yes, FMX and panel. Yes, they share frequency.
[AGENT][NEUTRAL] FMX and Pa are once every, yes, once every 5 years.
[CUSTOMER][NEUTRAL] And they share frequency?
[AGENT][NEUTRAL] They do, yes.
[CUSTOMER][NEUTRAL] OK, and periodic exam is 2 in 12 in 12 months and pro fee is 1 in 6 months.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. Any history for this patient that might affect the frequency?
[AGENT][NEUTRAL] Uh, one moment, let me check that.
[CUSTOMER][NEUTRAL] Like any history for
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so I do not have any uh applicable history on file for this number.
[CUSTOMER][NEUTRAL] OK. So it, I just have 4 codes. I want to know these codes and come under major or it's just not covered. So can I give all the four codes at once? Only want to know if this covered or not?
[AGENT][NEUTRAL] That's fine.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK. So the codes are [PII] and 9944.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] So 0367 is not going to be a covered procedure.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] 0431 is also not covered.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] 7953 is not covered.
[AGENT][NEUTRAL] 9223 is not covered and neither is 9944, so none of those are going to be covered procedures under this policy.
[CUSTOMER][POSITIVE] Wonderful. Could you please spell your name for me?
[AGENT][NEUTRAL] It's [PII]. Was there anything else I could help you with, [PII]?
[CUSTOMER][POSITIVE] No, thank you. Thank you so much for your help. I'm done with my question. Have a nice day.
[AGENT][POSITIVE] Of course, uh thanks for calling APL you too bye bye.
[CUSTOMER][NEUTRAL] Bye.