AccountId: 011433970860
ContactId: 0da84c54-77ee-4aa6-bfcc-494056ddac85
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 642030 ms
Total Talk Time (AGENT): 260572 ms
Total Talk Time (CUSTOMER): 181626 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/21/0da84c54-77ee-4aa6-bfcc-494056ddac85_20250521T13:07_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, good morning, this is [PII]. I wanna verify patient eligibility and benefits.
[AGENT][POSITIVE] All right, I'm happy to check on eligibility and benefits this morning. Can I get the patient's policy number?
[CUSTOMER][NEUTRAL] Yes, I have 021-34436.
[AGENT][NEUTRAL] OK, let me pull that up here one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] you
[AGENT][NEUTRAL] And patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Your
[CUSTOMER][NEUTRAL] It is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Thank you. And then [PII], are you looking for dental coverage or medical?
[CUSTOMER][NEUTRAL] Dental
[AGENT][NEUTRAL] Dental. OK. Patient is active on their dental plan. The effective date on here is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Some of your.
[AGENT][POSITIVE] And then if you need us to, we can also send a fax back with a breakdown or we can verbally give you whatever you need.
[CUSTOMER][NEUTRAL] May I have both?
[AGENT][POSITIVE] Yeah, absolutely. Let me just pull this up here.
[CUSTOMER][NEUTRAL] and then
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Uh, what information did you need from me verbally?
[CUSTOMER][NEUTRAL] Yes ma'am. First, can you please tell me if there's a waiting period missing tooth clause?
[AGENT][NEUTRAL] Yeah, absolutely. So, policy does have a missing tooth clause. Uh, looks like there is a waiting period of 12 months, and that would be for major expenses. That does include endodontic, periodontic, and oral surgery.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And do you have the um.
[CUSTOMER][POSITIVE] Exactly it would be satisfied?
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] So much
[AGENT][NEUTRAL] Their effective date was [PII], so the waiting period would have ended um [PII].
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, sorry, I'm writing this down.
[AGENT][NEUTRAL] Oh, it's OK.
[CUSTOMER][NEUTRAL] Alright, and this is calendar year?
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Alright, is there a deductible annual maximum?
[AGENT][NEUTRAL] Uh, yes, so their annual max is going to be 1500.
[AGENT][NEUTRAL] And it looks like their calendar year deductible is going to be $50. There is up to $150 per family.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is there any ortho coverage?
[AGENT][NEGATIVE] No ortho coverage.
[CUSTOMER][POSITIVE] Perfect. Any implant coverage?
[AGENT][NEGATIVE] Uh, no. Implants are not covered.
[CUSTOMER][POSITIVE] Perfect. And let's see 4 major, uh, crowns, bridges, and dentures, would that be 1 every 5 years for replacement?
[AGENT][NEUTRAL] Um, it looks like crowns and bridges are once every 7 years.
[AGENT][NEUTRAL] And then partials and dentures are showing once every 5.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] And what is the percentage on those as well?
[AGENT][NEUTRAL] Uh, let's see
[AGENT][NEUTRAL] Looks like that's gonna be paid at 40% of UCR.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And you said Endo and Pero, um, SRP and root canal, would those be 40% as well?
[AGENT][NEUTRAL] Mhm. Yes, ma'am.
[CUSTOMER][NEUTRAL] Oh, OK, and what is the frequency for those?
[AGENT][NEUTRAL] Um, I'm sorry, for SRP and what?
[CUSTOMER][NEUTRAL] And root canal.
[AGENT][NEUTRAL] Uh let's see.
[AGENT][NEUTRAL] Do you have any codes for either one of those I can check?
[CUSTOMER][NEUTRAL] Yeah, yes, um, Endo 3310 Imperio 4341.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you, let's see here.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So 3310 doesn't show any sort of limitation on it um just so it's paid at the 40%, then 4341, let me see here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um, and then it looks like 4341 is a maximum of 1 each quadrant for 24 months.
[CUSTOMER][NEUTRAL] OK, let's see, and for oral surgery, um, 70 to 10.
[CUSTOMER][NEUTRAL] What was the frequency be for that?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Uh, looks like there's no limitation as far as frequency, just covered at 40%.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And um
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] I'm just asking for a frequency and percentage if you could still help me for these codes.
[AGENT][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] OK, um, for fillings 2330?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] So it looks like it's a maximum of 1 each tooth for 24 months.
[AGENT][NEGATIVE] And replacements only covered if existing in place for 24 months.
[CUSTOMER][NEUTRAL] OK, see.
[CUSTOMER][POSITIVE] Thank you and see what codes for panel 0330.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] All right, so it looks like limitation on that.
[AGENT][NEUTRAL] Uh, limited to one X-ray procedure per 5 year, and it looks like it shares frequency with 210 also.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And could you tell me for cleaning, um, 11:10?
[AGENT][NEUTRAL] Yeah, so 11:10.
[AGENT][NEUTRAL] It's going to be.
[AGENT][NEUTRAL] A maximum of 1 per 6 months.
[CUSTOMER][NEUTRAL] OK, and for exam 01.
[CUSTOMER][NEUTRAL] 50.
[AGENT][NEUTRAL] 0150.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Looks like limited to 2 oral evaluation procedures in a 12 month period.
[CUSTOMER][NEUTRAL] OK, thank you, and one last one by 0274.
[AGENT][NEUTRAL] Let me check that here.
[AGENT][NEUTRAL] It looks like limited to 1 bite wing X-ray per 12 months.
[CUSTOMER][NEUTRAL] OK, thank you very much and may I have, oh, is there any history at all?
[AGENT][NEUTRAL] Um, let me double check here one moment.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] All right, so looks like last date of service on file was for [PII].
[AGENT][NEUTRAL] Um, patient did have a cleaning, it looks like and bite wings.
[AGENT][NEUTRAL] And pianofilm [PII].
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, and the code for the bite wings is the [PII].
[AGENT][NEUTRAL] Yes, uh-huh.
[CUSTOMER][NEUTRAL] OK, alright, is there a group name or a number?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yeah, let's take a look. Let's see.
[AGENT][NEUTRAL] Group name is Universal Trucking.
[AGENT][NEUTRAL] And then the group number is gonna be 13,590.
[CUSTOMER][POSITIVE] Perfect, thank you, and may I have a fax now?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yeah, absolutely. What's your fax number?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] Should we mark attention to anybody on there?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] No, it doesn't matter thank you though.
[AGENT][POSITIVE] OK, right, yeah, no problem. All right, I'm sending that now. Is there anything else that we can check on for you today?
[CUSTOMER][POSITIVE] No, that is all. Thank you so much for all of your help. Oh, may I have the reference number?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Absolutely. Call reference is gonna be my name with my last initial and then today's date. My name again is [PII], that's [PII], and then today's date.
[CUSTOMER][NEUTRAL] Alright, [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Alright, thank you so much for all of your help.
[AGENT][POSITIVE] You're welcome. Have a good day.
[CUSTOMER][POSITIVE] Thank you, you too, bye bye.
[AGENT][NEUTRAL] Bye-bye.