AccountId: 011433970860
ContactId: 1331759b-cdab-4b12-9a90-eb2965c9a0b6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1228180 ms
Total Talk Time (AGENT): 475030 ms
Total Talk Time (CUSTOMER): 286653 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/1331759b-cdab-4b12-9a90-eb2965c9a0b6_20250103T15:57_UTC.wav
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[AGENT][NEUTRAL] Hi, thanks for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Uh, this is [PII] from Dentalder's office. [PII], how are you doing?
[AGENT][POSITIVE] Oh, I'm doing so wonderful, thank you. How about yourself?
[CUSTOMER][POSITIVE] I'm fine, thank you for asking. I have just one patient and I need to help to get dental benefits.
[AGENT][POSITIVE] Yes, I'd love to help you with some dental benefits today. And can I have that policy number?
[CUSTOMER][NEUTRAL] Yeah. It's um 02566124.
[AGENT][NEUTRAL] 02566124, did I hear that correct my friend?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you. And
[AGENT][NEUTRAL] Well, I'm getting that policy pulled up, do you mind if I also go ahead and get a good callback number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect.
[AGENT][NEUTRAL] And your patient's first and last name and date of birth, please?
[CUSTOMER][NEUTRAL] Yeah, the patient is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. I do see her here. She's current and active with us. Would you like me to go ahead and get a fax back put together and sent out your way?
[CUSTOMER][NEUTRAL] Uh, yeah, you can send me the fax back.
[CUSTOMER][NEUTRAL] If we can do this particular patient over the phone, please.
[AGENT][NEUTRAL] Yes, absolutely. So do you want both the fax back and then you want benefits over the phone or?
[CUSTOMER][NEUTRAL] Yeah, both.
[AGENT][NEUTRAL] I just wanna make both, OK.
[AGENT][POSITIVE] Perfect.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Where what's the fax number I'm sending this to?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Perfect. And then could you spell your name for me, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you. I got that going your way, my friend, and then.
[AGENT][NEUTRAL] What questions can I help you with over the phone for this policy?
[CUSTOMER][NEUTRAL] Uh, so actually I need full benefit breakdown, but before that just want to confirm once, uh, this is a PPO plan, right?
[AGENT][NEUTRAL] Um, no, this is not a PPO plan, uh.
[AGENT][NEGATIVE] There's no network for this plan.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Is this an HMO because I just want to confirm once if patient can see our doctor here.
[AGENT][NEUTRAL] OK, yeah, so, um, this policy is through our company, um, so we pay everything. There is no plan, but the schedule of fees is put in that full breakdown that I just faxed your way. So every code covered is on that fax back and then it tells you any limitations on there and it's paid off based on the usual and customary rate.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] OK, so there are no boundation and patient can see a doctor, right?
[AGENT][NEUTRAL] Yeah, so the patient can see anybody as long as they're licensed.
[CUSTOMER][NEUTRAL] Oh, OK, got it. Uh, so starting with the basic breakdown like group name, number, effective date.
[AGENT][NEUTRAL] Yeah, their effective date is [PII]. Their group number is going to be 24313.
[AGENT][NEUTRAL] And the group name is Universal Trucking.
[CUSTOMER][NEUTRAL] What's the second what did you say?
[AGENT][NEUTRAL] Trucking T R U C K I N G.
[CUSTOMER][NEUTRAL] trucking.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um, OK.
[CUSTOMER][NEUTRAL] And uh what's the annual maximum and deductible?
[AGENT][NEUTRAL] Yep, the calendar year maximum is $1500 and the deductible is $50. The preventative expenses do not apply to the deductible, and I do wanna let you know that any benefit information I give you over the phone is just a verification of coverage and not a guarantee of payment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And um is there any family deductible?
[AGENT][NEUTRAL] Uh, the family deductible is $150.
[CUSTOMER][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] Coordination of benefit waiting period, missing the clause.
[AGENT][NEUTRAL] Um, there is a 12-month waiting period for all major, um, expenses and surgical expenses. The policy does have a missing tooth clause.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And I'm not sure about the coordination of benefits. It doesn't say anything about that.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Then, uh, major payment on sea or pre date?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, major service like round enter payment on trip date?
[AGENT][NEUTRAL] Um, it doesn't specify prep or receive date.
[CUSTOMER][NEUTRAL] Um, OK, uh, co-insurance, please, um, uh, like preventative basic measure.
[AGENT][NEUTRAL] Yeah, so preventative is covered at 100% of UCR and then basic expenses are covered at 80% of UCR. Um, all of the major expenses and oral surgery expenses, they do have that 12 month waiting period and they're covered at 40% of UCR.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh does this plan have any auto benefits?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK there's not.
[CUSTOMER][NEUTRAL] And uh endoed oral surgery covered at um 80% or 40%?
[AGENT][NEUTRAL] Um, they're covered under the major at 40% with a 12 month waiting period.
[CUSTOMER][NEUTRAL] OK, that's a problem. And uh sedation, anesthesia?
[AGENT][NEUTRAL] Um, I can look at the individual code for you. It's not.
[AGENT][NEUTRAL] Listed, but I can look at a code.
[CUSTOMER][NEUTRAL] Uh, OK, for edition, uh, we can use 9222.
[AGENT][NEUTRAL] All right, I don't show that as a covered code.
[CUSTOMER][NEUTRAL] 9223.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, I think is not covered.
[CUSTOMER][NEUTRAL] Um, all right, and, um, oh, policies, so there is, uh, just want to confirm one.
[AGENT][NEUTRAL] Um, hey, 92, 9220 and 9221, um, are both say deep sedation, general anesthesia. Those both have coverage on there.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And at 80% or 40% after 12 months?
[AGENT][NEUTRAL] Um, so, let me see, they're listed under majors, so it's gonna be the 40% 12 month waiting period.
[AGENT][NEUTRAL] And then there's the limitation on them.
[CUSTOMER][NEUTRAL] OK, and any history for the patient?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, I just want to know is there any history for the patient in previous service which can affect the frequency.
[AGENT][NEUTRAL] Well, this patient just became effective 2 days ago, so there's no history for this patient.
[CUSTOMER][NEUTRAL] OK, and last, uh, the procedures, if you can help me with 30 calls, I just need percentage in the frequency.
[AGENT][NEUTRAL] Yeah, which, which codes do you need?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Like 30 cos I have including the major endo radio and uh we can do as per your convenience like one at a time, 5 or 10 at a time, all at once.
[AGENT][NEUTRAL] Uh, I'm gonna have to do them all one at a time because I don't know them and I'm gonna have to search them individually for you.
[AGENT][NEUTRAL] I'm sorry, but do you want like the general frequencies first before we look at the codes?
[CUSTOMER][NEUTRAL] Um, OK.
[CUSTOMER][NEUTRAL] Um, yeah, we can do that also. So remaining codes are the last letter.
[AGENT][NEUTRAL] OK, so profe and.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, no, so I can ask remaining course later.
[AGENT][NEUTRAL] OK, perfect. Um, proceeds and cleanings are going to have a frequency of once every 6 months.
[AGENT][NEUTRAL] Exams have a frequency of 2 per 12 month period.
[AGENT][NEUTRAL] Bite wings.
[AGENT][NEUTRAL] are going to be covered once every 12 month period.
[AGENT][NEUTRAL] FMX and panoramics are once every 5 years.
[AGENT][NEUTRAL] Crowns and bridges are once every 7 years per tooth.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then partials and dentures are once every 5 years.
[CUSTOMER][NEUTRAL] OK, pleasear Avenue.
[CUSTOMER][NEUTRAL] And dentures are 5 years.
[CUSTOMER][NEUTRAL] Um, OK.
[CUSTOMER][NEUTRAL] So still I have remaining calls so many, so shall I?
[AGENT][POSITIVE] Yeah, absolutely. I can look them up for you.
[CUSTOMER][NEUTRAL] OK, and first of all you say, uh, exams are twice in 12 months, so, uh, does all the exams share frequency like 014 0 share with other exams?
[AGENT][POSITIVE] I'm so sorry. I
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] You said 0104?
[CUSTOMER][NEUTRAL] Yeah, 0140.
[AGENT][NEUTRAL] 40 I'm sorry.
[AGENT][NEUTRAL] Alright, 0140 is going to share a frequency with 012001500160 and 0180, which is limited to two oral evaluation procedures in any combination for 12 month period.
[CUSTOMER][NEUTRAL] Mhm. OK. Uh, next we have 0220.
[AGENT][NEUTRAL] 02 20.
[AGENT][NEUTRAL] All right, I see that one's covered under basic expenses with no limitation.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] OK, um,
[CUSTOMER][NEUTRAL] I want to confirm you say biting and SMS both are covered at uh preventive or basic.
[AGENT][NEUTRAL] Um, the bite wings are covered under preventative and then.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The radiographs, which I believe are the panoramics and FMX, are covered at 80%.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] Mhm. So next we have uh fluoride 1206.
[AGENT][NEUTRAL] You said 1206?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I don't have that code listed. I'm sorry.
[CUSTOMER][NEUTRAL] So, can you consider that it's not covered?
[AGENT][NEGATIVE] Yeah, if it's not on here, it's not covered.
[CUSTOMER][NEUTRAL] OK. Uh, next 1351.
[AGENT][NEUTRAL] I do have that covered under preventative.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And frequency and age limit is there any?
[AGENT][NEUTRAL] Hold on one sec.
[AGENT][NEUTRAL] It is 1 procedure for 36 months, um, made to permanent molar teeth only and limited to dependent children under the age of [PII].
[CUSTOMER][NEUTRAL] 4, OK.
[CUSTOMER][NEUTRAL] Uh, uh, next, we have, um, 2391.
[AGENT][NEUTRAL] All right, I see that's covered under.
[AGENT][NEUTRAL] Basic restorative and
[AGENT][NEUTRAL] It has two limitations. One second, let me see.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] The first limitation is replacement of existing only if in place for 24 months, and maximum of 1 each tooth per 24 months.
[CUSTOMER][NEUTRAL] OK. And uh does it downgrade it?
[AGENT][NEUTRAL] We don't downgrade.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Then next we have 2950.
[AGENT][NEUTRAL] I have 29.50 is covered under major expenses and AADD it has two limitations, hang on. First one is maximum of 1 per 7 year period, and the second one is limited to patients [PII] and over.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, uh, next 4341?
[AGENT][NEUTRAL] 4341.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That is covered under the periodontic expense, and it has one limitation, maximum of 1 each quadrant per 24 months.
[CUSTOMER][NEUTRAL] And um all 4 parts can be done on the same day?
[AGENT][NEUTRAL] Uh, yes, I don't have any limitation on that.
[CUSTOMER][NEUTRAL] OK, uh, next 4910?
[AGENT][NEUTRAL] 4910, let me find out for you.
[AGENT][NEUTRAL] Alright, I do have that one covered under periodontic, and it has just one limitation, maximum of 1 procedure every 6 months.
[CUSTOMER][NEUTRAL] Does it shared with regular clinics 1110?
[AGENT][NEUTRAL] It doesn't show that it's shared with anything, but 11:10 is covered under preventative.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] With the same frequency.
[CUSTOMER][NEUTRAL] Mhm. All right. Uh, next we have 4355.
[AGENT][NEUTRAL] 4355 is covered under periodontic and it is limited to
[AGENT][NEUTRAL] 1 each quadrant for 24 months.
[CUSTOMER][NEUTRAL] 4346.
[AGENT][NEUTRAL] I don't show 4346 listed as a covered.
[CUSTOMER][NEUTRAL] Mhm 4381.
[AGENT][NEUTRAL] I also don't, oh no, here it is. I'm sorry. Um, I do have that covered under periodontic and it has no limitation.
[CUSTOMER][NEUTRAL] Mhm. 4266.
[AGENT][NEUTRAL] I don't show that one covered.
[CUSTOMER][NEUTRAL] Mhm. Uh, next 6010.
[AGENT][NEUTRAL] No, I don't see that one.
[CUSTOMER][NEUTRAL] Mhm. 6058.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] And then uh we have 6740.
[AGENT][NEUTRAL] 6740.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, I'm sorry.
[CUSTOMER][NEUTRAL] 7140.
[AGENT][NEUTRAL] 7140 I do have listed under basic and it has one limitation.
[AGENT][NEUTRAL] Which is maximum one time per tooth.
[CUSTOMER][NEUTRAL] Uh, 7 to 10.
[AGENT][POSITIVE] All right. I do show that covered under oral surgery expenses with no limitation on it.
[CUSTOMER][NEUTRAL] Mhm. 7953.
[AGENT][NEUTRAL] 7
[AGENT][NEUTRAL] I don't show that one covered.
[CUSTOMER][NEUTRAL] Uh, uh, 90 to 10.
[AGENT][NEUTRAL] Uh no, I don't see that one either.
[CUSTOMER][NEUTRAL] 9944.
[AGENT][NEUTRAL] You said 9944?
[CUSTOMER][NEUTRAL] Mhm. A guards.
[AGENT][NEUTRAL] All right, I do not see.
[AGENT][NEUTRAL] Coverage for that either. I'm sorry.
[CUSTOMER][NEUTRAL] OK, and last code um.
[CUSTOMER][NEUTRAL] 624 5.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right. And uh what's the payer ID?
[AGENT][NEUTRAL] Uh, yes, payer ID is 60801.
[CUSTOMER][NEUTRAL] OK, 60 and [PII], uh, that's all for today. What's the call reference number we have?
[AGENT][NEUTRAL] You bet your call reference number is gonna be my name, [PII], first initial last name [PII], and today's date.
[CUSTOMER][POSITIVE] OK, and thank you so much for your help and have a good one. Stay safe.
[AGENT][POSITIVE] Oh, my pleasure. You too, take care.
[CUSTOMER][NEUTRAL] Bye now.
[AGENT][NEUTRAL] Bye bye.