AccountId: 011433970860
ContactId: 13046b86-b52a-421b-ad5a-e6d1167d51f2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1120060 ms
Total Talk Time (AGENT): 505033 ms
Total Talk Time (CUSTOMER): 546583 ms
Interruptions: 10
Overall Sentiment: AGENT=0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/17/13046b86-b52a-421b-ad5a-e6d1167d51f2_20250317T15:11_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling on behalf of the dental office to check eligibility and benefits for a patient on a recorded line. Can you help me with that?
[AGENT][NEUTRAL] I'm so sorry, what is your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you, [PII]. What is your callback number?
[CUSTOMER][NEUTRAL] [PII]. This is a direct line.
[AGENT][POSITIVE] Thank you so much, [PII] and what is that policy number I can help you?
[CUSTOMER][NEUTRAL] It's 02365891.
[AGENT][NEUTRAL] OK, I have that as 02365891. Thank you. And when you verify the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yes, it's [PII]. Um, do you want me to spell the last name?
[AGENT][NEUTRAL] No, I need the date of birth, please. Thank you.
[CUSTOMER][NEUTRAL] OK. It's [PII].
[AGENT][NEUTRAL] OK, thank you very much for the verification process. Now again, you're calling for eligibility and benefits, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK, I can assist you with that. The member shows effective as of [PII]. This policy shows active for the member.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, this plan follows usual customer and reasonable rates. There is no preferred provider network. It pays by UCR.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And once I'm done with the verbal breakdown I can also fax over a.
[AGENT][NEUTRAL] Um, schedule of benefits to you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me know when you're ready to start with the breakdown.
[CUSTOMER][POSITIVE] OK, can we start with the, so I already got the free schedule. It is UCR and right.
[AGENT][POSITIVE] Correct, it
[CUSTOMER][NEUTRAL] This, this is a calendar year plan or a fiscal year plan?
[AGENT][NEUTRAL] This is a calendar year plan?
[CUSTOMER][NEUTRAL] OK. Coordination of benefit is standard.
[AGENT][NEUTRAL] We did not coordinate benefits.
[CUSTOMER][NEUTRAL] OK, no CB. Can you verify the group name and group number?
[AGENT][POSITIVE] I certainly can one moment for you.
[AGENT][NEUTRAL] OK, the group number, I'm sorry, the group name is Universal Trucking Wall Street Systems.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, can you please spell the first name?
[AGENT][NEUTRAL] OK. Universal is spelled U N I V for Victor, E R S Sierra A L.
[CUSTOMER][NEUTRAL] OK. Universal.
[AGENT][NEUTRAL] Mhm and the second word is trucking.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Mhm. Can you spell that?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] T R U C [PII]
[CUSTOMER][NEUTRAL] CKI tracking, OK.
[AGENT][NEUTRAL] OK, Wall Street Systems.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, can you spell that also because I'm not able to get this name over here.
[AGENT][NEUTRAL] OK. The third word is Wall, that's spelled W A L L.
[CUSTOMER][NEUTRAL] Right, OK.
[AGENT][NEUTRAL] The next, the next word is street, [PII] R E E T.
[CUSTOMER][NEUTRAL] OK. Universal trucking Wall Street, NS.
[AGENT][NEUTRAL] And the last word?
[AGENT][NEUTRAL] The Last word is systems that's S Y S T like Tom EMS.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. S Y S T E N.
[AGENT][NEUTRAL] S
[CUSTOMER][NEUTRAL] It's.
[AGENT][NEUTRAL] OK, and the group number is 13003.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's it.
[AGENT][NEUTRAL] Yes, that is the group number.
[CUSTOMER][NEUTRAL] 13003. OK. One moment. It is getting updated.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, can you check if this provider is in-network or out of network or both?
[AGENT][NEUTRAL] This is not a plan that follows a network again it follows UCR.
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] So is there any waiting period missing to clothes?
[AGENT][POSITIVE] The waiting period of 12 months has been satisfied from the effective date.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] There, OK, there is a missing tooth cloth.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And how much is the plan maximum deductible amount?
[AGENT][NEUTRAL] Please note verification of benefits provided as I guarantee payment. There's a $1500 calendar year max with a $50 deductible.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And what about family deductible?
[AGENT][NEUTRAL] This is a couple plan.
[AGENT][NEUTRAL] So the deductible is $50 per person.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. And uh this patient is eligible for orthodontics benefit?
[AGENT][NEUTRAL] Orthodontic benefits are not covered with this policy.
[CUSTOMER][NEUTRAL] OK. And uh anything used or met from the $1550?
[AGENT][NEUTRAL] OK, let me check that for this here for you one moment please, [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] No, nothing has been used or met for this year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And uh can you provide me the percentage for diagnostic, preventive, basic, and major services?
[AGENT][NEUTRAL] Preventative is covered, of course, preventative is covered at 100%. Basic is covered at 80%, and major services are covered at 40%.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] 84. OK. And uh inlays and onlays are covered in layers only crown.
[AGENT][NEUTRAL] Crowns are covered at 40% under major.
[AGENT][NEUTRAL] And these are for coverage services.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. What about inlays and only? They are also covered, right?
[AGENT][NEUTRAL] I'm sorry, do you have a procedure code that I can check for you? Thank you.
[CUSTOMER][NEUTRAL] Yes, I, yes. OK. So for procedure composer that is 2393, is it downgraded or covered as it is?
[AGENT][NEUTRAL] OK, there are no downgrades on the plan. There are no downgrades, that's covered at 80%.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And uh major services are paid on the date or pre date?
[AGENT][NEUTRAL] Um, either or.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Either or, OK. And also, can you let me know endeddontics, periodontics, and oral surgery will come in basic or major services?
[AGENT][NEUTRAL] Uh, those are major services.
[CUSTOMER][NEUTRAL] OK. Implants are covered?
[AGENT][NEGATIVE] Implants are not covered.
[CUSTOMER][NEUTRAL] OK. What about bone grafts and consultation?
[AGENT][NEUTRAL] 7953 is not a covered benefit.
[CUSTOMER][NEUTRAL] And general anesthesia?
[CUSTOMER][NEUTRAL] Do you want the code?
[AGENT][NEUTRAL] Anesthesia is covered, I do.
[CUSTOMER][NEUTRAL] Covered. OK. OK. So for anesthesia, it is 9223. For inlays and onlys it is 2630.
[CUSTOMER][NEUTRAL] 26434 SRP 434143554381. Bridges 6240. Consultation 9310, a close guard 9944. I have two more 03670431. Can you please let me know if these codes are covered or not?
[AGENT][NEUTRAL] OK. I'm so sorry, [PII], um, you're going too fast. So what is the anesthesia code?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh, I'm sorry for that. It's 9223. Do you want me to give you all at once or one by one? We can go as your.
[AGENT][POSITIVE] No problem.
[AGENT][NEUTRAL] No, I just, no, I actually have them down. I just missed the anesthesia and the last two. I have the 0431. What was before that?
[CUSTOMER][NEUTRAL] 0367. Did you get for anesthesia 9223?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 9223, yes.
[CUSTOMER][NEUTRAL] Mhm OK.
[AGENT][NEUTRAL] OK. All right, thank you. That was 02367, is that correct?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] No, that was 0367.
[AGENT][NEUTRAL] 0367. OK, so I will go ahead and tell you 0367 and 0431 are not covered.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, now let me check for the other codes for you one moment please.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You can also let me know if there's any frequency for them.
[AGENT][NEUTRAL] OK, one moment please.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so for 9223 that is not showing printed on the fee schedule so I cannot say that that is a covered benefit again that's for the anesthesia 9223.
[CUSTOMER][NEUTRAL] right.
[AGENT][NEUTRAL] It does not show printed on the schedule of benefits so I cannot say that is that it is covered, OK? Now moving on to 2630 1 moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] A 2630 that shows covered under major at 40%. Let me get that frequency for you one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, that's a max of 1 for 7 year period, limited to patients age [PII] and over. Again, that's 1 for 7 year period for 2630.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 2643 that also falls under major 40%.
[CUSTOMER][NEUTRAL] Do.
[AGENT][NEUTRAL] And that has the same frequency 1 per 7 year period.
[CUSTOMER][NEUTRAL] OK. Uh, sorry, uh, 4 2740, it will be the same one time in seven years. 2740.
[AGENT][NEUTRAL] I'm sorry, that's a new code that you're asking me about, is that correct?
[CUSTOMER][NEUTRAL] Yes, yes, but because it is a major, so I asked you.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so 2740 that's covered under major that shares the same frequency 1 per 7 year period, that is correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, now going back to the code 4341 that is covered under major, that's 1 per 24 months. All four can be done on the same visit 4 341.
[AGENT][NEUTRAL] Now for 4381, 1 moment, let me make sure that one.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] 4381, that's covered under major. It has no frequencies. Again, 4381 shows no frequencies.
[CUSTOMER][NEUTRAL] all the patient.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so 6240, let me check that one for you.
[CUSTOMER][NEUTRAL] I had given you one more, with 4355.
[AGENT][NEUTRAL] OK, thank you. 435-5.
[CUSTOMER][NEUTRAL] That was
[AGENT][NEUTRAL] I have it here.
[CUSTOMER][NEUTRAL] 4381.
[CUSTOMER][NEUTRAL] I have given you 4381 also.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And for 4381 that is covered under major at 40% with no frequency for 4355, that is also covered under major, that's 1 per 24 months.
[CUSTOMER][NEUTRAL] original
[AGENT][NEUTRAL] OK, now I'm gonna go to 624-0, 1 moment.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 6240 that is covered under major and it shows 1 per seven-year period.
[CUSTOMER][NEUTRAL] 11
[AGENT][NEUTRAL] 9310.
[CUSTOMER][NEUTRAL] You know.
[AGENT][NEUTRAL] That is covered under
[AGENT][NEGATIVE] Basic at 80% with no frequency.
[AGENT][NEUTRAL] And the closer guard 9944 that is covered under major at 40%. Let me get that frequency for you please with me one moment.
[CUSTOMER][NEUTRAL] And they.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, that is limited to those aged [PII]+, and that's the max of 17-year period.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. And uh I was a little confused in 43554381. Can you please repeat that? 4355 is no frequency?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 4355 has 1 per 24 month frequency.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And 4381.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Has no frequency that's covered under major.
[CUSTOMER][NEUTRAL] OK. And uh this 4910 and 1110 shares the frequency?
[AGENT][NEGATIVE] No, they do not.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK. But it will be 40% 1 time in 6 years, 6 months for 4910?
[AGENT][NEUTRAL] 4910 that's once every 6 months that's covered under major.
[CUSTOMER][NEUTRAL] That.
[CUSTOMER][NEUTRAL] Major, OK. Can you also let me know if uh this patient has FMX and pano shares of frequency?
[AGENT][NEUTRAL] FMX and pay and share frequency that's one for 5 year period. Those are covered under basic.
[CUSTOMER][NEUTRAL] One time in 5 years, OK. Basic, that is 80% FMX and panel.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So deductible will apply? OK. What about vitamins and fluoride?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] The Bright wings are 1 per 12 month period under preventative.
[CUSTOMER][NEUTRAL] You.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And fluoride is once per 12 month period.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] Limited to under age [PII].
[CUSTOMER][NEUTRAL] You want more.
[CUSTOMER][NEUTRAL] OK. And uh this exams and cleaning shares the frequency? 012 010, 1110.
[AGENT][NEUTRAL] 1110, that's once every 6 months.
[AGENT][NEUTRAL] Exams are 2 for 12 month period.
[CUSTOMER][NEUTRAL] OK. And uh sea lens is one time in 36 months, right?
[AGENT][NEUTRAL] So are 1 per 36 months. That's correct, limit to dependent children under the age of [PII].
[CUSTOMER][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] Under preventative
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So for this patient, implants or and general anesthesia are not covered. Also, bone grafts are not covered.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] The procedure code for the anesthesia 9223 is not showing covered on this particular.
[AGENT][NEUTRAL] Schedule of benefits bone graft is not covered. That is correct. Orthodontics is not covered. That is correct. 0367, the cone beam that is not covered as well as the 0431 that is also not covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And also, can you let me know if this patient has any history which may affect the frequency for FMX and yes, OK, thank you.
[AGENT][NEUTRAL] Let me check the history for you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] OK, the member has had a bite wing that was on [PII]. The member is not eligible for that.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]. Yes, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, still touching.
[CUSTOMER][NEUTRAL] It is one time in 12 months, so the patient is not eligible.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, and also,
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Also on [PII], remember I had a comp exam.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And exams are 2 for 12 month period.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] And also had a pan on [PII], so it's not eligible for that.
[CUSTOMER][NEUTRAL] For pano, FMX and Pao.
[AGENT][NEUTRAL] Correct, not eligible, so not eligible for a bite wings, not eligible for Pin or FMX.
[AGENT][NEUTRAL] Um, let me check again we're still searching for you. Thank you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] No history for profy.
[CUSTOMER][NEUTRAL] We can
[AGENT][NEUTRAL] No history for fluoride. Now on [PII], a member did have um SRP done.
[CUSTOMER][NEUTRAL] This.
[CUSTOMER][NEUTRAL] OK. For which quadridge?
[AGENT][NEUTRAL] OK, let me check that for you. Give me a moment.
[AGENT][NEUTRAL] Still searching, OK, it shows for upper left and lower left.
[CUSTOMER][NEUTRAL] OK. Mhm.
[CUSTOMER][NEUTRAL] 1218 2024. So now patient is eligible 2026 for upper left and lower left.
[AGENT][NEUTRAL] Correct, that's what done. [PII] it was upper left, lower left.
[CUSTOMER][NEUTRAL] And.
[CUSTOMER][NEUTRAL] What about upper right and lower right?
[AGENT][NEUTRAL] I do not show that in the history.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Then I'm done with all my questions, [PII]. Uh, can you please provide me the reference number for this call?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Uh, [PII], we do not provide reference numbers. However, you can use my name [PII] last initial [PII] and today's date. Anything else I can assist you with, please?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][POSITIVE] No, thank you so much for your help. You have a nice day. Bye. Thank you. Bye.
[AGENT][POSITIVE] You're welcome, [PII]. Thanks for calling APL. Have a good day bye.
[AGENT][POSITIVE] Mhm thank you bye bye.