AccountId: 011433970860
ContactId: 140d2d61-7704-4dfe-8010-7bfcfc6225d9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 701830 ms
Total Talk Time (AGENT): 227407 ms
Total Talk Time (CUSTOMER): 131731 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/04/140d2d61-7704-4dfe-8010-7bfcfc6225d9_20250204T17:05_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hey Ms. [PII], this is [PII]. How are you?
[AGENT][POSITIVE] I'm doing good. How about you?
[CUSTOMER][POSITIVE] I'm doing good, thank you for asking. I was calling to get some information on a patient's policy for out of network services.
[AGENT][NEUTRAL] OK. May I please have the policy number?
[CUSTOMER][NEUTRAL] 592-903
[AGENT][NEUTRAL] And may I have a callback number please?
[CUSTOMER][NEUTRAL] [PII] no extension.
[AGENT][NEUTRAL] And may I have the patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] date of birth is [PII].
[AGENT][NEUTRAL] And how may I assist you?
[CUSTOMER][NEUTRAL] Yes ma'am, is this policy still active?
[AGENT][NEUTRAL] Let me check that for you.
[AGENT][NEUTRAL] For this policy, it is showing that it's currently active with the effective date for [PII].
[CUSTOMER][NEUTRAL] Is this a calendar year or benefit year?
[AGENT][NEUTRAL] Um, this is a per calendar year.
[CUSTOMER][NEUTRAL] OK, what's that group name?
[AGENT][NEUTRAL] Let me get that for you.
[AGENT][NEUTRAL] The group name is APLA and H group.
[CUSTOMER][NEUTRAL] APA and OK, and the group number?
[AGENT][NEUTRAL] 0033
[CUSTOMER][NEUTRAL] Can I know the maximum and has anything been used?
[AGENT][NEUTRAL] Let me check that for you.
[AGENT][NEGATIVE] As of right now no benefits has been used for this year.
[CUSTOMER][NEUTRAL] So it's the annual month?
[AGENT][POSITIVE] I'm pulling it up for you as well.
[CUSTOMER][POSITIVE] Oh OK, thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Apologies.
[CUSTOMER][NEUTRAL] Mm that sounds
[AGENT][NEUTRAL] And verification of coverage does not guarantee the payment of the claim. It's showing that the member has a calendar year max of $750.
[CUSTOMER][NEUTRAL] So no longer the 12:50.
[AGENT][NEUTRAL] Let me check that.
[AGENT][NEUTRAL] I'm not seeing a 12:50.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so you said the maximum is 750?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, and what's the deductible?
[AGENT][NEUTRAL] $50.
[CUSTOMER][NEUTRAL] Is Ortho covered?
[AGENT][NEGATIVE] It says ortho is not covered.
[CUSTOMER][NEUTRAL] OK, can I know the percentages for preventative, basic, and major for out of network?
[AGENT][NEUTRAL] That is for preventative, the preventative is showing that it's at 100 preventative expenses is at 100%.
[AGENT][NEUTRAL] And you said for a major?
[CUSTOMER][NEUTRAL] Um, basic and major.
[AGENT][NEUTRAL] Basic expenses is showing at 80%.
[AGENT][NEUTRAL] And I'm not seeing any major benefits listed on here.
[CUSTOMER][NEUTRAL] OK, have this, have their plan changed? I'm just curious because last year they had major coverage. I'm just trying to make sure do I need to get.
[CUSTOMER][NEUTRAL] A whole new breakdown for them or?
[AGENT][NEUTRAL] Let me check because look she has enhanced.
[AGENT][NEUTRAL] Hold on.
[AGENT][POSITIVE] I do apologize. She actually has enhanced. Her calendar year is [PII].
[AGENT][NEUTRAL] And the calendar year deductible is the $50 per covered insurance with $150 per family.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The preventative is at the 100%.
[AGENT][NEUTRAL] The basic expenses and basic restorative expenses is at 80%.
[AGENT][NEUTRAL] For the major it is showing 50%.
[AGENT][NEUTRAL] And it still shows orthodontic treatment is not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, what about implants are implants covered?
[AGENT][NEUTRAL] Let me check that for you. May I have a code for that?
[CUSTOMER][NEUTRAL] Um, I have a couple, um, it's 6, what about 6010.
[AGENT][NEUTRAL] Let me check that one for you.
[AGENT][NEUTRAL] OK, I'm not seeing that code listed.
[CUSTOMER][NEUTRAL] OK, what about 6057?
[AGENT][NEUTRAL] That code is not listed either.
[CUSTOMER][NEUTRAL] 6058.
[AGENT][NEUTRAL] That one's not listed. I'm gonna just put implants in and see.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It was like that's all of them then that's fine.
[AGENT][NEUTRAL] It says implants, placements, removal, and all related services are not covered.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, is she eligible to have code 11:10?
[AGENT][NEUTRAL] Check that one.
[AGENT][NEUTRAL] Yes, it does show that. Let me pull the.
[AGENT][NEUTRAL] Limitations up for you.
[AGENT][NEUTRAL] For that cold, she has a maximum of 1 procedure per 6 months.
[CUSTOMER][POSITIVE] So she's eligible for it.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, what about 0120?
[AGENT][NEUTRAL] And let me make sure on that if she hadn't used it before I tell you yes.
[AGENT][NEUTRAL] OK, yes, she is eligible for the previous one, the the 11:10.
[AGENT][NEUTRAL] And then the 0120.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] She has a limit to 2 oral evaluation procedures in any combination per 12 months. So let me see if she used that.
[AGENT][NEUTRAL] So for that one, it does show that she has previously used that one on [PII] of last year.
[CUSTOMER][NEUTRAL] So is she eligible to have another exam?
[AGENT][NEUTRAL] She can only get 2, she can get 2 every 12 months, so she is eligible for another another exam.
[CUSTOMER][NEUTRAL] OK, what about 0274?
[AGENT][NEUTRAL] That one is showing that she's eligible for the 2, for the 1.
[AGENT][NEUTRAL] Per 12 months.
[AGENT][NEUTRAL] 0
[AGENT][NEGATIVE] And she actually had that one done in July of last year, so she's not eligible for that one, no.
[CUSTOMER][NEUTRAL] So she's not ill.
[CUSTOMER][NEUTRAL] OK, and what about 0210?
[AGENT][NEUTRAL] She is limited to 1 X-ray procedure for 5 years.
[AGENT][POSITIVE] She's actually eligible for that procedure this year.
[CUSTOMER][NEUTRAL] And then you said it's 1 every 5 years?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And when was her last one?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Alright, and can you spell your first name for me?
[AGENT][NEUTRAL] Yes, it is spelled [PII] last initial of H and today's date, and also Chastity, would you like for me to send you her fax back?
[CUSTOMER][POSITIVE] Yes, that'll be fine, yes ma'am.
[AGENT][NEUTRAL] OK, may I have that fax number?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] And to the attention.
[CUSTOMER][NEUTRAL] Chastity.
[AGENT][POSITIVE] OK, I will get that submitted over to you. Is there anything else that I can assist you with today?
[CUSTOMER][NEUTRAL] No ma'am, but I use your name for the reference number correct?
[AGENT][NEUTRAL] Yes, you use my first name, last initial, and today's date.
[CUSTOMER][POSITIVE] OK, alright, thank you so much, Mr. [PII].
[AGENT][POSITIVE] You're welcome. Thank you for calling American Public Life. Have a great day.
[CUSTOMER][NEUTRAL] Uh huh you too.
[AGENT][NEUTRAL] Bye