AccountId: 011433970860
ContactId: 09edee03-0f6d-4ba6-bab7-e5c26b5ed62f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 607309 ms
Total Talk Time (AGENT): 245763 ms
Total Talk Time (CUSTOMER): 195933 ms
Interruptions: 3
Overall Sentiment: AGENT=1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/24/09edee03-0f6d-4ba6-bab7-e5c26b5ed62f_20250224T20:57_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], um, I wanted, uh, dental benefit breakdown.
[AGENT][POSITIVE] All right, it would be my pleasure to assist you. May I ask your name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you, [PII] and what is a good call back number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, [PII], and what is the policy number for the patient?
[CUSTOMER][NEUTRAL] 02560658
[AGENT][NEUTRAL] And the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And then date of birth is [PII].
[AGENT][NEUTRAL] All right, thank you. And I understand you're needing a breakdown.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, I do have a breakdown I can fax to you. Janice's policy is active.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Effective date is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The policy does not participate in a network, it pays at a percentage of UCR.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And just to let you know, there is a 12 month waiting period on major procedures.
[AGENT][NEUTRAL] And on the breakdown that I faxed you, [PII], it will have the calendar year max, deductibles, frequencies, limitations.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so I actually called earlier in order to get that faxed over, but I haven't received anything so can you actually verbally give me a breakdown?
[AGENT][NEUTRAL] Sure, yeah, and I'm gonna go ahead and fax it again just to make sure, OK?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I can give you the uh verbal breakdown. Now I will advise that all benefits given over the phone is a verification coverage, not a guarantee of payment.
[AGENT][NEUTRAL] Is that fax back 7 the number [PII]?
[CUSTOMER][POSITIVE] Yeah, that's correct.
[AGENT][NEUTRAL] OK. She said she sent it.
[AGENT][POSITIVE] Yeah I'm gonna go ahead and send it again now.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm sorry you haven't received it. So the calendar year max is $1500 per calendar year. There is a $50 deductible up to $150 per family, and the deductible does not apply to preventive expenses.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Preventive is covered at 100% of ECR.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Radiographs, FMX basic and basic restorative is covered at 60% of UCR.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then your major services, including endodontic, periodontic, prosthodontic repair, and oral surgery is covered at 40% after the 12 month waiting period has been satisfied.
[CUSTOMER][NEUTRAL] Family dental care
[CUSTOMER][POSITIVE] Hi good and you?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, profies and cleanings. I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][NEUTRAL] I'm sorry, so, um, real quick for bye wings, what would that be under for 0274?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 0274 bye wings are under preventive services, and those are
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I told her
[AGENT][NEGATIVE] Once for 12 month period and there's no history on file.
[CUSTOMER][POSITIVE] So it's gonna be covered at 100%, right?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Got it. OK, go ahead, keep going.
[AGENT][NEUTRAL] And the puppies and cleanings or once every 6 months.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Exams are 2 for 12 month period, they do uh share frequency.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the.
[CUSTOMER][NEUTRAL] Hi, yes, so it looks like they were testing, um, you do have a balance. It looks like your insurance did make a payment, but, um, you did have a done.
[AGENT][NEUTRAL] FMX and Pennos is once every 5 years.
[AGENT][NEUTRAL] Crowns and bridges are once every 7 years and partials and dentures once every 5 years.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That is fine.
[CUSTOMER][NEUTRAL] So when we did the cleaning, the exam, and the X-rays.
[CUSTOMER][NEUTRAL] Uh, what we build.
[AGENT][NEUTRAL] Any, any other specific questions?
[CUSTOMER][NEUTRAL] 345
[CUSTOMER][NEUTRAL] Yes, actually give me one moment can I put you on hold real quick? OK, thank you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Hi, OK, so for an FMX, um, what is that covered under?
[AGENT][NEUTRAL] FMX and Pao are covered under basic.
[CUSTOMER][NEUTRAL] So 60% only, OK.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] You're welcome. OK, give me one moment, OK? I'm gonna put you on hold real quick.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes, I'm still here.
[CUSTOMER][NEUTRAL] Hi, OK, so how, how much is it for for a 4341?
[AGENT][NEUTRAL] Now 4341 is considered major and there's a 12 month waiting period prior to benefits being payable.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, what about a 42, 0, I'm sorry, go ahead, sorry.
[AGENT][NEUTRAL] And 43.
[AGENT][NEUTRAL] And any of your endo periodontic expenses, postedontic repairs, and oral surgery, they're all subject to that 12 month waiting period.
[CUSTOMER][NEUTRAL] OK, so a 4260 is 40% and and those 3330 is also 40%.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What about a 6010?
[AGENT][NEUTRAL] 6010, let me check that for you. What is the 6010?
[CUSTOMER][NEUTRAL] Implants.
[AGENT][NEUTRAL] Oh, implants are not covered, nor our services uh for implants.
[CUSTOMER][NEUTRAL] Not covered. OK, 9952.
[CUSTOMER][POSITIVE] Accrual adjustment.
[AGENT][NEUTRAL] OK, 9952.
[AGENT][NEUTRAL] Chicken.
[AGENT][NEUTRAL] 9952 is covered, that's also under major.
[CUSTOMER][NEUTRAL] Major, OK, 9944, which is a night guard.
[AGENT][NEUTRAL] Mhm. That is also under major, subject to that 12 month waiting period.
[CUSTOMER][NEUTRAL] OK, and then for bye wings, what's the frequency for that?
[AGENT][NEUTRAL] By wings are 2, once for 12-month period.
[CUSTOMER][NEUTRAL] 2 for 12 months?
[AGENT][NEUTRAL] Once per 12 month period, I apologize.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Monday
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then is there any um history for this patient?
[AGENT][NEGATIVE] No history on file.
[CUSTOMER][NEUTRAL] No history on file OK.
[CUSTOMER][NEUTRAL] OK, is there any frequencies for a 4910?
[AGENT][NEUTRAL] For 4910, of course that's under your major.
[AGENT][NEUTRAL] And the 4910 is once for 6 months once every 6 months, sorry.
[CUSTOMER][POSITIVE] OK, what about the, oh we already said for, OK, then that's actually all I would need. Thank you so much for your help. May I have a reference number too?
[AGENT][NEUTRAL] The reference number is my name and today's date, and I spell my name [PII]. And you haven't received that fax yet?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, actually I still haven't.
[AGENT][POSITIVE] Oh my goodness, cause I sent it.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] To that number that you verified.
[CUSTOMER][NEUTRAL] Yeah, the [PII], that is correct.
[AGENT][NEUTRAL] Mhm. Yeah.
[AGENT][POSITIVE] Well, hopefully you'll get it soon.
[CUSTOMER][NEUTRAL] I don't know.
[CUSTOMER][POSITIVE] OK, thank you so much for your help though.
[AGENT][POSITIVE] It's been my pleasure. And [PII], is there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, that'll be all thank you.
[AGENT][POSITIVE] Thank you for calling APL. You have a wonderful afternoon. Take care.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye bye.