AccountId: 011433970860
ContactId: 280fbed2-47c8-4779-9428-fd6bbe6ae46d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1184540 ms
Total Talk Time (AGENT): 363753 ms
Total Talk Time (CUSTOMER): 299834 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/18/280fbed2-47c8-4779-9428-fd6bbe6ae46d_20250418T14:00_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII]. I'm calling regarding patients dental benefit on behalf of provider's office. Could you please help?
[AGENT][NEUTRAL] Yes, I can help you out today, [PII]. Did you say claim status?
[CUSTOMER][POSITIVE] Wonderful, uh, dental benefits.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. And then do you have the policy number?
[CUSTOMER][NEUTRAL] I do, so 02610646.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And then what's a good callback number in case our call gets dropped, [PII]?
[CUSTOMER][NEUTRAL] Sure. [PII].
[AGENT][NEUTRAL] OK, perfect. And then the patient's first and last name and date of birth, please?
[CUSTOMER][NEUTRAL] Yes, uh, [PII], [PII], birthday?
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, just one second while I pull up her benefits.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so I have her benefits pulled up. Are there certain benefits you were wondering about?
[CUSTOMER][NEUTRAL] Uh, you need to check that uh like routine dental coverage really, but, uh, first, can you confirm that provider status the right network or not.
[AGENT][NEUTRAL] Yes, so it looks like their network.
[AGENT][NEUTRAL] Is Carrington.
[CUSTOMER][NEUTRAL] Carrington.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And they're participating with them at that location?
[AGENT][NEUTRAL] It says Carrington PPO.
[CUSTOMER][NEUTRAL] Carrington and it is single or family coverage for uh [PII]?
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Looks like this is single.
[CUSTOMER][NEUTRAL] Single member on coverage perfect. And do you have group name and number for the policy?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so the group name is Hamilton Riker.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, R Y K E R.
[CUSTOMER][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the group number is 70029.
[CUSTOMER][NEUTRAL] 20296. Perfect. Thank you. And do you show any guideline regarding policies COB codation of benefit will be standard or non-duplicated.
[AGENT][NEUTRAL] So we do not coordinate benefits.
[CUSTOMER][NEUTRAL] OK, and what's the original effect you did?
[AGENT][NEUTRAL] Let's see, it looks like the effective date is [PII].
[AGENT][NEUTRAL] And this policy.
[CUSTOMER][NEUTRAL] 25. OK, so that's yeah.
[AGENT][NEUTRAL] Yes, it's currently active.
[CUSTOMER][POSITIVE] Wonderful. Any calendar year or fiscal year I'm asking?
[AGENT][NEUTRAL] So this is not a guaranteed payment, it's just a verification of coverage. It looks like for her policy, the calendar year maximum is $500 per covered insured.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then calendar year deductible is $50 per covered insured up to $150.
[AGENT][NEUTRAL] And deductible does not apply to preventative services.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, only best you can meet you. Got you. Thank you. And, and up to today, any anything to declare the waiting period.
[AGENT][NEUTRAL] Yes. Mhm.
[AGENT][NEGATIVE] Yes, this policy does have a missing tooth cloth.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And how about waiting period?
[AGENT][NEUTRAL] Sorry, what was that?
[CUSTOMER][NEUTRAL] Waiting period, if any?
[AGENT][NEUTRAL] T
[AGENT][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] So there is no waiting period for the calendar year max or deductible.
[CUSTOMER][POSITIVE] Perfect. It said 500 megs, 50% deductible and any accumulation this year I think use automate none.
[AGENT][NEUTRAL] None.
[CUSTOMER][NEUTRAL] Nothing years, nothing much. OK, ma'am. Perfect. Any dental history? No history at all whatsoever?
[AGENT][NEUTRAL] Uh, let me see. I will double check and see if they have used anything so far.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK. She has not used anything as of this year.
[CUSTOMER][NEUTRAL] This year nothing is nothing. OK. And uh no history at all?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] From the beginning.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] No, she has not used anything for this policy.
[CUSTOMER][NEUTRAL] OK, now ortho is covered or not. We have separate ortho maximum available?
[AGENT][NEUTRAL] Sorry, can you repeat that?
[CUSTOMER][NEUTRAL] Orthodontic services. I'm asking if they're covered in this plan or not.
[AGENT][NEUTRAL] OK. OK. Orthodontic treatment is not covered.
[CUSTOMER][NEUTRAL] No. Thank you. And asking for coverages, what are the co-insurance levels first for preventive basic nature?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So this policy does not cover major.
[CUSTOMER][NEUTRAL] OK, on the preventive and basic.
[AGENT][NEUTRAL] Yes, sir. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got you. Thank you very much for that. And also endoperio and oral are covered or not?
[AGENT][NEUTRAL] Hm
[AGENT][NEGATIVE] No, not covered.
[CUSTOMER][NEUTRAL] All end of period all of them are not covered. OK, thank you and composed fillings, uh, downgrades or not?
[AGENT][NEUTRAL] No, we do not downgrade.
[CUSTOMER][NEUTRAL] No downgrade for this plan. OK. Simple extractions are covered and not as well.
[AGENT][NEUTRAL] No doctor. Mhm.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Do you happen to have the, the CDT code?
[CUSTOMER][NEUTRAL] I said the code 7140 for extraction.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it looks like extractions fall under basic.
[AGENT][NEUTRAL] And basic.
[CUSTOMER][NEUTRAL] OK, and.
[AGENT][NEUTRAL] Yes, basic expenses is 100% of allowable.
[CUSTOMER][NEUTRAL] OK. 100% and diagnostic preventive. So that's also under 100%.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Sorry, that extraction, I just wanted to let you know that it says maximum one time per tooth. Well, for an extraction. And then what was the next one?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Preventive and diagnostic, you said they are covered, right? So, uh they're on the, on the preventive 100% as well?
[AGENT][NEUTRAL] Yes, so preventative expenses, 100% of allowable.
[CUSTOMER][NEUTRAL] OK, and can you give me frequencies for that preventive diagnostic services like exams, clinics, and X-rays?
[CUSTOMER][NEUTRAL] Or do you want me to get the quotes?
[AGENT][NEUTRAL] Yes, so it looks like.
[AGENT][NEUTRAL] For full mouth X-rays and pan panoramics, it's once every 5 years.
[CUSTOMER][NEUTRAL] 17586. OK, thank you.
[AGENT][POSITIVE] Yes, and I can also fax you over this benefit plan.
[CUSTOMER][NEUTRAL] Oh, it's like, uh, not like a full just 6 to 7 courses. So can you give me a call please? I can give you all together.
[AGENT][NEUTRAL] Yes, that's fine.
[CUSTOMER][POSITIVE] OK, thank you. So you're all together one by one.
[CUSTOMER][NEUTRAL] Oh yeah
[AGENT][NEUTRAL] Sorry, what was the first one?
[CUSTOMER][NEUTRAL] Uh, you want quotes one by 1, 0120 1st code.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, 4 0120 falls under preventative and that's 100% of allowable.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] The limitation is limited to 2 oral evaluation procedures in any combination per 12-month period.
[CUSTOMER][NEUTRAL] 12 months, OK. 0 150 will be the same, can you check?
[CUSTOMER][NEUTRAL] Comprehensive exam.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] 0150 is the same.
[CUSTOMER][NEUTRAL] OK. 11
[CUSTOMER][NEUTRAL] Next is 1110 prophy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and that code also falls under preventative, which is 100% of allowable.
[CUSTOMER][NEUTRAL] He he.
[AGENT][NEUTRAL] And the limitations are maximum of 1 procedure for 6 months.
[CUSTOMER][NEUTRAL] So 6 months for 11. OK, 0274 next.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and that also falls under preventative. So that would be the 100% of allowable.
[AGENT][NEUTRAL] And then the limitations for that one.
[AGENT][NEUTRAL] Is limited to one bite wing X-ray procedure for 12-month period.
[CUSTOMER][POSITIVE] Excellent.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. 02 20 next.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] just normal.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and this falls under basic as well. So, or sorry, basic expenses is 80% of allowable and there's no limitation.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][POSITIVE] Oh no. 100% perfect. Thank you. Uh, next is fluoride 1208.
[CUSTOMER][NEUTRAL] I got a stop in here
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] OK, that code is not on this policy.
[CUSTOMER][NEUTRAL] One
[CUSTOMER][NEUTRAL] I'm sorry, what did you say?
[AGENT][NEUTRAL] Sorry, this code is not on this policy.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so it's not covered. How about sealants, 1351?
[AGENT][NEUTRAL] What was the code?
[CUSTOMER][NEUTRAL] 1351.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so sealant falls under preventive 100% of allowable and there is a limitation.
[AGENT][NEUTRAL] And that is maximum of 1 procedure per 36 months.
[AGENT][NEUTRAL] And limited to dependent children under age [PII].
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Qualification food genius any tooth restriction like cover for molars, permanent molars, anything.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, so it says applications made to permanent molar teeth only.
[CUSTOMER][NEUTRAL] I'm sorry. Only?
[AGENT][NEUTRAL] Yes, applications made to permanent molar teeth only.
[CUSTOMER][NEUTRAL] Only permanent moors, OK, and space maintenance, I have two quotes, 1510 and 1575.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hello, you're checking?
[AGENT][POSITIVE] Sorry, I'm checking for you.
[CUSTOMER][NEUTRAL] Sure, sure.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so for 15-10, this also falls under preventative, 100% of allowable, and it does have a limitation.
[AGENT][NEUTRAL] Which limited to dependent children under age [PII].
[AGENT][NEUTRAL] And maximum one time per tooth.
[CUSTOMER][NEUTRAL] Uh, same for 1575 as well.
[AGENT][NEUTRAL] Uh, 1575 is not on this policy.
[CUSTOMER][NEUTRAL] OK, and I have two more codes uh [PII] and [PII].
[CUSTOMER][NEUTRAL] OK about you or
[AGENT][NEUTRAL] OK, just a moment.
[CUSTOMER][NEUTRAL] With the apple cups.
[AGENT][NEUTRAL] OK, and it looks like neither of those codes are on this policy.
[CUSTOMER][NEUTRAL] OK, neither of them cover. Perfect. So yes, that's all for that, really. And can you help me with your mailing address and payer ID please?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, of course.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] the organization.
[AGENT][NEUTRAL] So our claims address is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] 950.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Wonderful.
[CUSTOMER][NEUTRAL] OK. And the payer ID?
[AGENT][NEUTRAL] And the payer ID is 60801.
[CUSTOMER][POSITIVE] Excellent. OK. And do we have call, uh, reference for conversation.
[AGENT][NEUTRAL] Yes, it would be my first name.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] Last initial [PII] and then today's date.
[CUSTOMER][POSITIVE] Wonderful. So yeah, that's all for my benefit. Thank you very much for your help a wonderful day.
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with while I have you on the line?
[CUSTOMER][POSITIVE] Uh, no, that's the all concern for today, OK? Thank you once again and wonderful day.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][POSITIVE] Yes, yes, thank you for calling APL Frank. Have a good day.
[CUSTOMER][POSITIVE] Have a good one. Take care. Thanks.
[AGENT][NEUTRAL] OK.