AccountId: 011433970860
ContactId: 24861482-de0e-43c0-8597-77dcb304f6d7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 485880 ms
Total Talk Time (AGENT): 199767 ms
Total Talk Time (CUSTOMER): 235903 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/04/24861482-de0e-43c0-8597-77dcb304f6d7_20250304T16:52_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey, good morning, [PII]. My name is [PII]. I just have a few questions about a benefit breakdown.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the benefits and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, [PII], no extension.
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] 02588271
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], uh, [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment, and I am showing that the policy is active, it's been effective since [PII]. And what questions did you have today?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, um, my first question is, since this started on [PII], will it start again next year on [PII] or on [PII]?
[AGENT][NEUTRAL] This is a calendar year, so [PII].
[CUSTOMER][NEUTRAL] [PII]. OK, awesome. [PII], is there a COB on this plan?
[CUSTOMER][NEUTRAL] He said that um he went to the old.
[AGENT][NEUTRAL] Um, no, there's no coordination of benefits, however, we receive the claim or, you know, whenever we receive it, we'll go ahead and process it.
[CUSTOMER][NEUTRAL] OK, I got you and is there a student age or dependent age limit?
[AGENT][NEUTRAL] Um, depending on the cold, there are some that are limited to depending on children aged [PII] or [PII].
[CUSTOMER][NEUTRAL] OK, I got you, um, and then our accounts paid on seat date or prep date?
[CUSTOMER][NEUTRAL] And.
[AGENT][NEUTRAL] Um, either or there's no specification, whichever you prefer.
[CUSTOMER][NEUTRAL] OK, I got you. Does the preventative come out of the uh maximum?
[AGENT][NEUTRAL] That's preventative, yes.
[CUSTOMER][POSITIVE] Yes, OK, I got you.
[AGENT][NEGATIVE] But not the deductible.
[CUSTOMER][NEUTRAL] OK, I got you. Not the deductible. I see here on the fact that it says radiographs and FMXs are covered at 80%. Is that, uh, correct? I just wanted to double check.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][POSITIVE] All right, awesome and is that for like all X-rays including like bite wings and PAs?
[AGENT][NEUTRAL] Um, bite wings are actually covered under preventative for our policy, so that's at 100%. And then, um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You said PA. Do you have a code for the PAs?
[CUSTOMER][NEUTRAL] Yes, 0220.
[AGENT][NEUTRAL] 0220 is under basic um at 80%.
[CUSTOMER][POSITIVE] OK, I got you 80% and 80%. Alright, awesome. And then for code 4341, can we do all four quads the same day?
[AGENT][NEUTRAL] 4341. Now this policy covers um preventative and basic expenses. There's no major coverage on this policy. So um major for us is endodontic, periodontic, proteodontic, and oral surgery. Um, those would all not be covered under this policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I got you. All right, is, um, is there a way I could give you some codes just to verify that they will be covered or not covered?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, do you want them all at once or one at a time?
[AGENT][POSITIVE] Oh no, we can do all at once.
[CUSTOMER][NEUTRAL] OK, it is a few, OK?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, alright, the first one is 7140, 72 1072 0 go ahead, go ahead.
[AGENT][NEUTRAL] Wait, I have a question, sorry.
[AGENT][NEUTRAL] Um, you said you did receive a copy of the fax back?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And you, but these codes that you're searching for, you're wanting to know if they're covered or not?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So if the code is not on the fax back, it's not covered, but I mean I can go through the fax back with you if you like.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] OK, I got you. Oh, let me just, um, scan through it really quickly for, um, um, for fillings, did you guys downgrade on this plan?
[AGENT][NEUTRAL] Um, no, ma'am, no downgrades.
[CUSTOMER][NEUTRAL] No, OK, awesome. So no downgrades on that. Alright, since um 4346 is part of Pero, are you guys covered, um, does this, is this code covered under this plan?
[AGENT][NEUTRAL] Um, no, we don't cover major charges or expenses on this policy.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I got you and what is the frequency for fillings for 2391?
[AGENT][NEUTRAL] Let's see, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 2391, uh basic restorative H and F. Hold on one second. So H is resist um replace existing only in place for 24 months, and then F is maximized maximum of 1 tooth per quadrant.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I got you. And then, um, I see that exams are two every 12 months. Does that also go for a limited exam for the 0140?
[AGENT][NEUTRAL] 0140. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, this policy.
[AGENT][NEUTRAL] So the 0140 is paired with 150 and 12 um 120 and 160.
[CUSTOMER][NEUTRAL] Mhm. OK, I got you. There are some plans that do not let us do treatment same day for 0140. Is that the case for this one?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, there's no specification.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] OK awesome um and um for the PA no you no you're fine.
[AGENT][NEUTRAL] Wait, wait, wait, wait. I'm sorry. Hold on one second, let me double, let me double back. You said some plans don't um process under 0140?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, some plans don't let us do treatment same day for 0 140. Is that the case for this one?
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] So 0140 isn't a covered code on this policy, it's 0150, but um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It is a paired code, so, uh, it has the same frequency or limitation.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I got you and how about for 9110?
[AGENT][NEUTRAL] 9110.
[AGENT][NEUTRAL] Um, so that's under basic at 80, with no limitation.
[CUSTOMER][POSITIVE] 80, no frequency? OK, awesome. And this 10, I forgot to ask you for 0220, does that one have any limitations?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 0220 hold on one second. No, it doesn't.
[CUSTOMER][NEUTRAL] No, OK. Alrighty and um the very last code uh 1208.
[AGENT][NEUTRAL] Hm
[AGENT][NEUTRAL] So 1208 is not a covered code on this policy.
[CUSTOMER][NEUTRAL] Not covered. Alrighty, what is the uh group name for this plan?
[AGENT][NEUTRAL] Um, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So the group name is Management, analysis and Utilization.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the group number is 70056.
[CUSTOMER][NEUTRAL] Analysis.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Alright, and it was management analysis. What was the last word? I'm sorry.
[AGENT][NEUTRAL] That's OK, utilization.
[CUSTOMER][NEUTRAL] Utilization.
[CUSTOMER][POSITIVE] Alrighty, alright, well that is everything that I needed thank you so much for your help today.
[AGENT][POSITIVE] You're very welcome, [PII]. Well, thanks for calling APL and I hope you have a great day.
[CUSTOMER][POSITIVE] Thank you you too.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.