AccountId: 011433970860
ContactId: 174a7870-3245-41a5-b8fe-cb3395cea5ce
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 642119 ms
Total Talk Time (AGENT): 187324 ms
Total Talk Time (CUSTOMER): 345580 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/18/174a7870-3245-41a5-b8fe-cb3395cea5ce_20250318T14:12_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], uh, my name is [PII]. I'm calling from the Parada's dental office. Could you please help me with the verification of a patient?
[AGENT][NEUTRAL] I sure can, [PII], what is your callback number please?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, sure, let me get that for you one second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's [PII].
[AGENT][NEUTRAL] Thank you [PII], what is that policy number please?
[CUSTOMER][NEUTRAL] That's 02361937.
[AGENT][NEUTRAL] OK, to repeat, I have that as 02361937. Thank you. Verify the patient's name and date of birth.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] That, that's [PII] with the date of birth, [PII].
[AGENT][NEUTRAL] Thank you very much for the verification process and you're calling to verify eligibility for the member, is that correct?
[CUSTOMER][POSITIVE] Yeah, that's correct.
[AGENT][NEUTRAL] OK, I can assist with that. The member shows effective as of [PII], and this policy shows active for dental for her.
[CUSTOMER][NEUTRAL] All right. And uh just confirm the plan name will be Universal Trucking and the group number 13611, correct?
[AGENT][NEUTRAL] Um, before I agree to that, give me one moment, um, that is correct, thank you.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK. So since uh uh there is no network for this uh policy, right? Uh, since our provider,
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK, so can we use the uh use CRP schedule?
[AGENT][NEUTRAL] The plan follows UCR.
[CUSTOMER][NEUTRAL] Alrighty and um what would be the coordination of benefits with that?
[AGENT][NEUTRAL] We do not coordinate benefits.
[CUSTOMER][NEUTRAL] Alright, and could you please confirm, is there any pre-authorization required for this policy?
[AGENT][NEUTRAL] No, there is not.
[CUSTOMER][NEUTRAL] OK. And could you please verify the currently your maximum applies to with your services?
[AGENT][NEUTRAL] All services to Max does.
[CUSTOMER][NEUTRAL] OK. And could you please provide me the maximum and deductibles remaining, individual, uh, maximum deductible and family deductible?
[AGENT][NEUTRAL] Please note verification of benefits provided does not guarantee payment. The member has a $1500 calendar year max with a $50 deductible. She has not used anything or met anything towards that.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For this year?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. So uh $1500 for the max is still remaining and uh $150 for the family and $50 for the individual uh deductible is remaining the same, right?
[AGENT][NEUTRAL] The member does not have not met the deductible for this year now as far as the family one moment thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The family has not made the family deductible as well.
[CUSTOMER][NEUTRAL] So the $150 is still remaining, right?
[AGENT][POSITIVE] That is correct, [PII].
[CUSTOMER][NEUTRAL] All right. And um this one from there is no orthodontic implant services covered under this policy, right?
[AGENT][NEUTRAL] The plan does not cover orthodontics or implants.
[CUSTOMER][NEUTRAL] OK. All right. And uh just to confirm, the coverage percentage of this policy will be 100 for preventive diagnostic, 80 for basic, um, and major is 40, right?
[AGENT][NEUTRAL] OK, preventative is 100, basic 80, and measures 40. That is correct.
[CUSTOMER][NEUTRAL] OK. And uh I have this, uh, patient's fax back um just 11 concern. Uh, as in the fact, uh there is um uh cos that's that not showing in the fax is not covered for this patient, for this plan.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] So the codes which are not listed in the facts is not covered, right?
[AGENT][POSITIVE] That is correct. The codes listed on the scheduled benefits are worth covered, um.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, and is there any history for this patient that might affect the frequency?
[AGENT][NEUTRAL] The member has no history at all on the plan?
[CUSTOMER][POSITIVE] All right, thanks so much for that and um.
[CUSTOMER][NEUTRAL] OK, uh, is there any downgrades to the posterior composites?
[AGENT][POSITIVE] No, there are no downgrades at all on this policy.
[CUSTOMER][NEUTRAL] So there is no downgrade for the crowns also 2740 and 2750, right?
[AGENT][POSITIVE] That is correct. There is no downgrade on this policy at all.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, uh, for the crowns which just and then the specific you don't see date.
[AGENT][NEUTRAL] Um, either or.
[CUSTOMER][NEUTRAL] Either see date or prep date.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK, one second, please.
[CUSTOMER][POSITIVE] Alrighty, thank you sir. OK, thank you so much for your patience and for the core build up, uh, 295-02952 and 2954, is it considered as pre and DB core major?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Those are considered as major.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Major or the, OK. For the code 2950, can we do the 2950 and crowns on the same day?
[AGENT][NEUTRAL] It does not state.
[CUSTOMER][POSITIVE] Not stated right? so submitting a predetermination is good.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] That can be done.
[CUSTOMER][NEUTRAL] OK. And um for the SRP 43414342, is it have any uh quadon limitation on how many cordons are allowed on the same day?
[AGENT][NEUTRAL] Uh, those are 1 per 24 months and all 4 can be done on the same visit.
[CUSTOMER][NEUTRAL] All right. And for the 4355 uh 4381 and 4910, what would be the coverage percentage of the, these three quotes?
[AGENT][NEUTRAL] Those are all under major.
[CUSTOMER][NEUTRAL] 40%. All right. And for the 4355, can we do the 4355 and exams on the same day?
[AGENT][NEUTRAL] It does not state.
[CUSTOMER][NEUTRAL] OK. And is it requires any narratives, doctor's narratives for that?
[AGENT][NEUTRAL] I'm sorry, can you repeat that question?
[CUSTOMER][NEUTRAL] Does the 4 code 4355 requires any doctor's narratives?
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Alright, and for the code 4381, can we do the 4381 and SRP on the same day?
[AGENT][NEUTRAL] It doesn't state.
[CUSTOMER][NEUTRAL] All right. That's code for 910 shares frequency with the prophylaxis.
[AGENT][NEGATIVE] It does not.
[CUSTOMER][NEUTRAL] OK, and for the code 4910, does it require any history of surgery or a therapy? Any history is required for 4910?
[AGENT][NEUTRAL] It does not state.
[CUSTOMER][NEUTRAL] OK, and uh what would be the frequency and coverage percentage of the code 9110 and 9230?
[AGENT][NEUTRAL] OK, that was 9110 and 9310, is that correct?
[CUSTOMER][NEUTRAL] 9110 and 9230.
[AGENT][NEUTRAL] 9230. OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So 9310, OK, that falls under basic at 80%, no frequency.
[CUSTOMER][NEUTRAL] I'm sorry, I'm so sorry, uh 9110, 9110, no, 9310.
[AGENT][NEUTRAL] OK, so 9110, it falls under basic at 80%, no frequency.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, and the second code again, please, just to verify.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 99,230.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] OK, 9230 falls under major at 40%. It shows no frequency.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] All right. Does these two courts require a doctor's narratives?
[AGENT][NEUTRAL] It does not state
[CUSTOMER][NEUTRAL] OK, one second.
[CUSTOMER][NEUTRAL] One moment, let me update that. Bear with me. OK. And uh since uh there's no network in the policy, uh, what will be the assignment of benefits for this uh plan, uh, does the payment goes to the patient or the provider?
[AGENT][NEUTRAL] If the provider submits the claim correctly, payment goes to the provider.
[CUSTOMER][NEUTRAL] Um, you mean if, if there is a signature on file, um, for the ARB, uh, the payment will, will go to pro provider or if not the payment go to patient, is that what you mean?
[AGENT][NEUTRAL] That is correct, [PII] if the claim is submitted correctly, it goes to the provider.
[CUSTOMER][NEUTRAL] OK. So, uh, so that's correct, um, uh, that, is that what you mean, right? So there's the signature on file, the payment goes to provider or if not, uh, it's good to patient, right?
[AGENT][POSITIVE] That is correct. That means that the claim is submitted correctly. That is correct, yes.
[CUSTOMER][NEUTRAL] Oh, OK. One second. OK. Um, one moment, let me double check if there any information I missed. One moment, please. Bear with me.
[CUSTOMER][NEUTRAL] Um, one more concern. There is no, uh, plan, uh, group name and group number stated in the, uh, facts of this patient. Is there any reason?
[AGENT][NEUTRAL] Is there a reason for that? No, there's no reason for that. It's just not on the information that's submitted to as a fax back, but again I can verify the information with you again if you would like.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, no, oh, let me double check the information.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, one moment please.
[CUSTOMER][NEUTRAL] Um, for the code 4381, uh, is there, uh, any frequency for the code 4381?
[AGENT][NEGATIVE] There's no, no frequency for that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, uh, I think I covered up all the information I required for this patient. Thank you so much for helping me out. And could you please provide your name and reference number for this call?
[AGENT][NEUTRAL] You're welcome, [PII]. We do not provide reference numbers. You can use my name [PII] last initial [PII] in today's date. Anything else I can assist you with with this number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] Um, just to confirm one more time, uh, the subscriber name is [PII] [PII] with the date of birth [PII], and the plan name is Universal Trucking and the group number 13611, correct?
[AGENT][POSITIVE] That information is correct.
[CUSTOMER][POSITIVE] OK, OK, thank you so much, [PII], uh, for providing all those information about this patient and thank you so much for helping me out and have a great day bye.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] You as well, [PII]. Thank you for calling APL. Take care. Bye.
[CUSTOMER][NEUTRAL] Bye.