AccountId: 011433970860
ContactId: 269a0aa8-5d86-412e-8b96-462880df9cfa
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1448660 ms
Total Talk Time (AGENT): 435828 ms
Total Talk Time (CUSTOMER): 485623 ms
Interruptions: 4
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/12/269a0aa8-5d86-412e-8b96-462880df9cfa_20250512T15:53_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] Hi [PII], this is [PII] calling from the provider's office to verify the eligibility and benefits for the patient. Could you please help me with that?
[AGENT][NEUTRAL] Yes, I'm sorry. Can you repeat that slowly? You said eligibility and what was the second part?
[CUSTOMER][NEUTRAL] Benefits
[AGENT][POSITIVE] Benefits, OK, yes, I can help you with the eligibility and benefits. And may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure. The callback number is [PII].
[AGENT][POSITIVE] Thank you. And just for my notes, can you spell your first name for me, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Alright, and [PII], um, may I have the member's policy number?
[CUSTOMER][NEUTRAL] Member ID is 02295286.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII] and the date of birth is [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 the policy is active. It's been effective since [PII]. And what type of benefits did you want to go over today?
[CUSTOMER][NEUTRAL] So could you please help me with the group number?
[AGENT][NEUTRAL] Sure, the number is 70069.
[CUSTOMER][NEUTRAL] Thank you. So what would be the group name or the employer name?
[AGENT][NEUTRAL] ATC like Alpha, Tango Charlie, Healthcare Services LLC.
[CUSTOMER][NEUTRAL] OK, so it's this a dental PPO plan?
[AGENT][NEUTRAL] This is a dental policy, um, hold on one moment, let me see the plan.
[AGENT][NEUTRAL] And this policy is on the Carrington PPO network.
[CUSTOMER][NEUTRAL] OK, so here the patient is a subscriber, right? [PII], whose date of birth is [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. So is this a plan?
[AGENT][NEUTRAL] Yes, this is the calendar year.
[CUSTOMER][NEUTRAL] OK, what will be the coordination of benefits?
[AGENT][NEUTRAL] There's no coordination of benefits for our dental policies. We'll process it as it comes in.
[CUSTOMER][NEGATIVE] So there is no coordination of benefits.
[AGENT][NEUTRAL] Correct, whether you submit to us first or another company first, when we receive it, we'll go ahead and process it. There's no coordination of benefits for dental for us.
[CUSTOMER][NEUTRAL] OK. Is there any missing to close or waiting period in this plan?
[AGENT][NEUTRAL] There is a missing tooth clause. There's no waiting period because major is not covered on this policy.
[CUSTOMER][NEUTRAL] OK, and is the missing tooth cloth permanent?
[AGENT][NEGATIVE] Um, there's no specification for that under the exclusions. It just says this policy does have a missing tooth cloth.
[CUSTOMER][NEUTRAL] OK. Does this plan require any pre-authorization?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, so is the provider in or out of network?
[AGENT][NEUTRAL] Um, for the list of providers, I can either um provide you with Carrington's phone number or the website, but we don't have access to their list. It's a different company.
[CUSTOMER][NEUTRAL] So is it based on the Carrington participation?
[AGENT][NEUTRAL] Yes, it's a Canton PPO policy.
[CUSTOMER][NEUTRAL] To
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] However, if you're not, if your provider is not a Carrington provider, the benefits are still the same.
[CUSTOMER][NEUTRAL] So in and out of network are the same benefits, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, and what about the fee schedule? Is it, uh, the same as Carrington?
[AGENT][NEUTRAL] Yes, ma'am. This policy is on the Carrington PPO network, so it's all Carrington.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] OK, thank you. So what will be the individual maximum family deductible and individual deductible?
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Thank you and you have to make a transfer request.
[AGENT][NEUTRAL] So the calendar year max is $500 and the deductible is $50. This is an individual policy, um, but it is up to $150 per family.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Is it a 250 for family? 250.
[AGENT][NEUTRAL] 150.
[CUSTOMER][NEUTRAL] OK. So, for the maximum and deductibles, is anything used or met?
[AGENT][NEUTRAL] No, um, he has not used any of the max or met the deductible yet for 2025.
[CUSTOMER][NEUTRAL] OK, OK, so here the individual maximum applies to virtual services.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah, the calendar maximum applies to which all services.
[AGENT][NEUTRAL] Yes, all dental services, that's the max he can use.
[CUSTOMER][NEUTRAL] OK, so the max applies to all covered services, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, what about the deductible?
[AGENT][NEGATIVE] The deductible does not um does not apply to preventative.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And does this plan cover orthodontics?
[AGENT][NEUTRAL] Um, orthodontic treatment is not covered.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Is it due to the age limit or completely not covered?
[AGENT][NEGATIVE] It's not covered at all.
[CUSTOMER][NEUTRAL] OK. Now, could you please provide me the coverage percentages for preventive basic preventive and basic services?
[AGENT][NEUTRAL] Preventative is at 100%, basic is at 80%.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] OK, so major services like crowns, and just, bridges all are not covered, right?
[AGENT][NEUTRAL] Right. Major for us includes endodontic, periodontic, prosodontic, and oral surgery, so all those codes.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] OK. So oral surgery is also not covered. Is it also under major?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] What about oral surgery?
[AGENT][NEUTRAL] Oral surgery is under major, so that is not covered on this policy.
[CUSTOMER][POSITIVE] Yes yes
[CUSTOMER][NEUTRAL] OK, and same goes with implant as well, right?
[AGENT][NEUTRAL] Implant placement, removal, and all related services are not covered on this policy.
[CUSTOMER][NEUTRAL] OK, thank you. So here I have some specific procedure codes with me. So could you please help me with the coverage percentages for those quotes?
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] Sure, um you can provide them all at once.
[CUSTOMER][NEUTRAL] Sure. 022002302392239323947210 and 9944.
[AGENT][NEUTRAL] All right. Were there any others?
[CUSTOMER][NEUTRAL] Uh, I only need the coverage percentages for these calls.
[AGENT][NEUTRAL] All right, hold on one moment, OK?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Hello, [PII].
[CUSTOMER][NEUTRAL] I'm here.
[AGENT][POSITIVE] All right, thank you so much for holding. I apologize for that wait. Um, so all of the codes have the same percentage of 80%.
[AGENT][NEUTRAL] Uh, with the exception of 7210, is not covered and 9944 is not covered.
[CUSTOMER][NEUTRAL] OK, thank you. So could you please fax back a copy of benefit for this patient?
[AGENT][NEUTRAL] Sure, what's a good fax number for you?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that's attention, [PII]?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] Do I need to put attention, [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And that's fax number [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. Well, I'm sending this over to you now. Was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] Yes, could you please help me with the patient history for any of the preventive services that might affect the frequency?
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] No
[AGENT][NEUTRAL] [PII], code 001500021000929.
[AGENT][NEUTRAL] And 01110 were used. Um, let me see what this other claim is.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Uh, could you please repeat the codes once more for the data service [PII].
[AGENT][NEUTRAL] OK, um, 01206.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 00150.
[AGENT][NEUTRAL] 00210.
[AGENT][NEUTRAL] 00929.
[CUSTOMER][NEUTRAL] And um
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] And 01110.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Good thank you.
[CUSTOMER][NEUTRAL] Any other history?
[AGENT][NEUTRAL] No, that's the only, we've only processed two claims for the member.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So could you please help me with the frequency for exams in general?
[CUSTOMER][NEUTRAL] 4346
[CUSTOMER][NEUTRAL] 4355.
[AGENT][NEUTRAL] For exams, um, hold on one moment, like the oral evaluations?
[CUSTOMER][NEUTRAL] Yes and uh or the evaluation limited.
[CUSTOMER][NEUTRAL] Uh, periodic or evaluation and comprehensive exams. Do you want the quotes?
[AGENT][NEUTRAL] OK, what are the codes for those?
[CUSTOMER][NEUTRAL] OK. It is 01200140015010180.
[AGENT][NEUTRAL] Oh, those are all shared. It's 2 for 12-month period.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 0180 is not covered with that. It's just.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] OK. So 0180 is not covered. All the other exams are having a frequency of 2 and 12 months.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][POSITIVE] Correct, for 120, 40, 50, and 60.
[CUSTOMER][NEUTRAL] OK, what about the frequency for bite wings?
[AGENT][NEUTRAL] Fight wings are once per 12-month period.
[CUSTOMER][NEUTRAL] OK, what about FMX and Pau and do they share frequencies?
[AGENT][NEUTRAL] Once every 5 years, and no, they don't share frequencies.
[CUSTOMER][NEUTRAL] OK, so it is once in 5 years, not calendar, right?
[AGENT][NEUTRAL] Once every 5 years, every 5 calendar years.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So, if you're saying yes, it will be calendar, right?
[AGENT][NEUTRAL] Yes, ma'am, every year, once every 5 years.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so can we update calendar year once every 5 calendar year?
[AGENT][NEUTRAL] Calendar year and year is the same thing. You can say whichever you prefer.
[CUSTOMER][NEUTRAL] OK, thank you. So they both don't share frequencies, right? But, but both are having the same frequency of 1 in 5 calendar, but they don't share frequencies.
[AGENT][NEGATIVE] By wings is once per 12-month period, and then you ask about the full mouth X-rays and panels, that's once every 5 years. They do not share frequencies.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, thank you. And what about prophylaxis frequency and age limit?
[AGENT][NEUTRAL] Cleaning once every 6 months.
[AGENT][NEUTRAL] Um, if it's a child.
[CUSTOMER][NEUTRAL] And any age limit for child pro?
[AGENT][NEUTRAL] Go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, I'm sorry, I was asking if there is any age limit for child property.
[AGENT][NEUTRAL] Yes, and I was trying to answer your question. It's limited to dependent children under age [PII].
[AGENT][NEUTRAL] No.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] And you prefer share frequency with the codes 4346 and 4910?
[AGENT][NEUTRAL] No, Profies do not share um codes with anything.
[CUSTOMER][NEUTRAL] OK, and what about the frequency and age limit for fluorides and salines?
[AGENT][NEUTRAL] Let's see hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Maximum of 1 procedure for 12 months.
[AGENT][NEUTRAL] Limited to dependent children under age [PII]?
[AGENT][NEUTRAL] If it's an adult, limited to dependents.
[CUSTOMER][NEUTRAL] That is buffalo right.
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Uh, I was asking for the frequency age limit for fluorides.
[AGENT][NEUTRAL] Right, that's what I was providing. Did you need me to repeat that for you?
[CUSTOMER][NEUTRAL] I just want to confirm that the frequency is 1 in 12 months and it's for under age [PII], right?
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] So yes, the, the maximum of 1 procedure per 12 months, if it's a child limited to dependent children under age [PII], if it's an adult, limited to dependent children aged [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And they're considered as preventative, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, what about the frequency and age limit for silence 135191352?
[AGENT][NEUTRAL] 1352 is not covered on this policy. 1351.
[AGENT][NEUTRAL] Is maximum 1 procedure per 36 months limited to dependent children under age [PII]?
[AGENT][NEUTRAL] And applications made to molar teeth only.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So for fluorides, uh, 1206 and 1208 is having same frequencies and age limit, right?
[AGENT][NEUTRAL] 1205.
[CUSTOMER][NEUTRAL] 1206 and 1208.
[AGENT][NEUTRAL] 1206 is not
[AGENT][NEUTRAL] Neither are on this policy.
[CUSTOMER][NEUTRAL] Uh, are they both having same frequencies? 1206 and 1208 fluorides?
[AGENT][NEUTRAL] OK, as I just stated, code 1206 and code 1208 is not on this policy. It's not a cover code.
[CUSTOMER][NEUTRAL] OK. So, are composites downgraded to amalgam?
[AGENT][NEUTRAL] Um, yes, there are amalgam, um, codes here.
[CUSTOMER][NEUTRAL] Uh, yes
[CUSTOMER][NEUTRAL] OK, so is the terms that applicable for Molas or premola?
[AGENT][NEUTRAL] It's not specified, ma'am. When you see the fax back, you'll see the codes for ammogram. I don't know how to pronounce that, but it doesn't have that type of specification. It only gives a replacing existing only if in place for 24 months.
[AGENT][NEUTRAL] And maximum of 1 tooth per 24 months. That's, that's all it gives us.
[CUSTOMER][NEUTRAL] OK, so there is a downgrade.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. I'm sorry, seas are considered as preventative, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK, so crowns are not covered. And what about 2950, 2952, and 2954, are they covered under this plan?
[AGENT][NEUTRAL] Can you give those codes again, please?
[CUSTOMER][NEUTRAL] 295-02952 and 2954 core build up post.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] 2950 is not covered on the policy. 2952 is not on the policy.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And neither is 2954.
[CUSTOMER][NEUTRAL] OK. What about 4341 and 4342?
[AGENT][NEGATIVE] Those are major codes, Major is not covered on this policy.
[CUSTOMER][NEUTRAL] OK, what about 4346?
[AGENT][NEUTRAL] Any major codes, including endodontic, periodontic, prosodontic, and oral surgery are not covered by this policy.
[CUSTOMER][NEUTRAL] OK. So, uh, just want to know 435-54381 and 4910 all are on the major.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, now benches, bridges are not covered and what about 9110?
[CUSTOMER][NEUTRAL] I was.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] It's covered under basic at 80%.
[CUSTOMER][NEUTRAL] OK, what about the frequency? Any frequency limitations?
[AGENT][NEGATIVE] No, there's no frequency.
[CUSTOMER][NEUTRAL] OK, and what about 9230? Is it covered?
[AGENT][NEUTRAL] No, 9230 is not a cover code on this policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. What about 9945 and 9946?
[CUSTOMER][NEUTRAL] Yes and they you do maximum of.
[AGENT][NEGATIVE] Neither codes are listed on the fax bag.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] This is all you can help me with find it.
[CUSTOMER][POSITIVE] Oh, yes, that would be good and can I do that?
[CUSTOMER][NEUTRAL] OK. So, for out of network, what will be the payment of benefits? Will the payment goes to the provider or to the patient?
[AGENT][NEUTRAL] There is no out of network. The benefits are the same whether the provider is a Carrington provider or not.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. Uh, so, let me once more summarize the thing that is the group number is 70069 with the group name ATC Healthcare Services LLC and here the patient is a subscriber, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK, and you are following, uh, Carrington fee schedule and also participation is also based on the Carrington.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And yeah, the individual maximum is 500 family deductible 150, individual deductible 50, and no auto coverage. And your preventive and basic are covered at 180%. No major services are covered and or is also not covered, right?
[AGENT][POSITIVE] You said the basic, basic is covered at 80. OK, yes, that's correct.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, so that's all I have for today. So could you please spell your name for me and help me with the card reference number?
[AGENT][NEUTRAL] My name is [PII] The first initial to my last name is [PII]. There is no call reference number, but you can use my name in today's date.
[CUSTOMER][POSITIVE] Thank you so much, [PII], for helping me out and have a nice day. Take care. Bye-bye.
[AGENT][POSITIVE] You're welcome, [PII]. Was there anything else I can assist you with today?
[CUSTOMER][POSITIVE] That's all I have for today, thank you.
[AGENT][POSITIVE] Alright, thanks for calling APL. Bye-bye.