AccountId: 011433970860
ContactId: 2a3b87f3-7c20-4841-8075-3ffc9d40af9e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 620309 ms
Total Talk Time (AGENT): 229290 ms
Total Talk Time (CUSTOMER): 235036 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/07/2a3b87f3-7c20-4841-8075-3ffc9d40af9e_20250307T20:30_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], I needed to get a breakdown for a patient.
[AGENT][POSITIVE] OK, well, I can definitely help you with the breakdown. May I have your name and a good contact number?
[CUSTOMER][NEUTRAL] Uh, my name is [PII] and the contact number is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] It is 02586586.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] That would be Mr. [PII] and 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 that the policy is active. It's been effective since [PII].
[AGENT][NEUTRAL] And did you need a copy of the um fax back or you have particular questions about it?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, can you send me a fax back like a, uh, yeah, the whole breakdown, yes ma'am. So let me grab.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so on the, um, oh.
[CUSTOMER][NEUTRAL] Oh, I need to grab the um.
[CUSTOMER][NEUTRAL] The fax number, can you give me one second?
[AGENT][POSITIVE] Oh, sure, take your time.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hey my dear.
[AGENT][NEUTRAL] Hey, yes.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Hey, so the fax number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And should I put attention [PII]?
[CUSTOMER][NEUTRAL] Yeah, that's fine.
[AGENT][NEUTRAL] OK, and that was [PII]?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, so on the fax that it shows you the calendar year max, the deductible, all the percentages, any frequencies, exclusions, um, the three ways to file a claim, and then there's a list of um like covered codes. If the code you're looking for isn't on this list, it's not covered by the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, but then, uh, OK, it is the Carrington network and then.
[CUSTOMER][NEUTRAL] Is this a PPO plan?
[AGENT][NEUTRAL] Now, this one is a PPO, um, the benefits are the same. If your provider is not a Carrington provider, there's just like an additional percentage that they get off the balance if your provider is Carrington, if not, the benefits are all the same. They just don't get that percentage.
[CUSTOMER][NEUTRAL] OK, OK, so let me just.
[AGENT][NEUTRAL] And I looked to see if there was any history on file for you, but we haven't filed, we haven't processed any claims for them yet.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And it's 24,890 [PII]. OK, it's saying the payer, um, ID is what it is, yeah, that's OK, got it.
[AGENT][NEUTRAL] 6
[AGENT][POSITIVE] You got it.
[CUSTOMER][NEUTRAL] Oh, do you, did you want to go over it with me like really quick, or does it have to be a fast back? OK, so, um, do you accept assignment of benefits to non-participating providers?
[AGENT][NEUTRAL] Whatever you need, sure.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Um, we do, but there's no, there's no real assignment of benefits. however we receive it, we'll process it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, individual deductible.
[AGENT][NEUTRAL] $50.
[CUSTOMER][NEUTRAL] And any deductibles paid?
[AGENT][NEUTRAL] Not yet.
[CUSTOMER][NEUTRAL] And is this applying to preventative basic or major?
[AGENT][NEUTRAL] The deductible, um, basic and major.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Individual maximum.
[AGENT][NEUTRAL] 500 per insured per calendar year.
[CUSTOMER][NEUTRAL] And are there uh any benefits used?
[AGENT][NEUTRAL] No, not yet.
[CUSTOMER][NEUTRAL] And maximum is 0101.
[CUSTOMER][NEUTRAL] And ortho coverage?
[AGENT][NEGATIVE] Um, no orthodontic coverage.
[CUSTOMER][NEUTRAL] Uh, preventative.
[AGENT][POSITIVE] It's covered at 100%.
[CUSTOMER][NEUTRAL] Basic
[AGENT][NEUTRAL] 80.
[CUSTOMER][NEUTRAL] And it's major 50.
[AGENT][NEGATIVE] A major is not covered on this policy, only preventative, basic, basic, restorative, and then um radiograph and FMX. Preventative is the only thing that's covered at 80% I'm sorry, at 100% everything else is 80%.
[CUSTOMER][NEUTRAL] OK, hold on one second. So Bridges, crowns, um, Edo, that's all covered at 80, um, dentures 80. 0 wait, OK, wait, let me go back then.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] So the policy doesn't cover any major coverage um expenses and for us major is endodontic, periodontic, proteodontic, and oral surgery, all those codes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEGATIVE] So those are not covered.
[AGENT][NEUTRAL] I'm not.
[CUSTOMER][NEUTRAL] OK, so crowns, bridges, implants, and dentures are not covered.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm per maintenance.
[AGENT][NEUTRAL] Perrio is under major.
[CUSTOMER][NEUTRAL] It's the code 4910.
[CUSTOMER][NEUTRAL] OK, so that's not covered.
[AGENT][NEUTRAL] Correct, but I can double check it for you. Hold on one moment.
[AGENT][NEUTRAL] You said [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Yeah, that's not on here, 4910.
[CUSTOMER][NEUTRAL] OK, so, uh, what are simple extractions considered?
[AGENT][NEUTRAL] Simple extractions like 7140.
[CUSTOMER][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It doesn't give me a code, yeah, but yes, 7140.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] That's it. OK, so that's.
[CUSTOMER][NEUTRAL] Like a simple extraction.
[AGENT][NEUTRAL] Mhm, that's covered under basic at 80%.
[CUSTOMER][NEGATIVE] Missing tooth cloths.
[AGENT][NEGATIVE] There is a missing tooth cloth.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] OK, so exam frequencies, the 2 per calendar year?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Cleanings.
[AGENT][NEUTRAL] Once every 6 months.
[CUSTOMER][NEUTRAL] Bite wings.
[AGENT][NEUTRAL] Um, once per 12 month period.
[CUSTOMER][NEUTRAL] FMX
[AGENT][NEUTRAL] SMX is 80% um once every 5 years.
[CUSTOMER][NEUTRAL] Panos.
[AGENT][NEUTRAL] Once every 5 years.
[CUSTOMER][NEUTRAL] And fluoride.
[AGENT][NEUTRAL] Flora, let me see if there's a frequency Flo. Hold on one second. Um, this would be, oh, he's an adult. So hold on one second.
[AGENT][NEUTRAL] So it's a maximum of 1 procedure per 12 months and limited to dependent children aged [PII].
[CUSTOMER][NEUTRAL] Uh, perio SRP, the codes would be 4341.
[AGENT][NEUTRAL] 4341.
[AGENT][NEUTRAL] No, that's not on here.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oral cancer screen?
[AGENT][NEUTRAL] Um, what do you have a code for that? I don't think it's on here, but I can check for you.
[CUSTOMER][NEUTRAL] 0431.
[AGENT][NEUTRAL] 431.
[AGENT][NEUTRAL] No, it's not on here.
[CUSTOMER][NEUTRAL] Uh, dentures, bridges, crowns, those are probably 1 in 60.
[CUSTOMER][NEUTRAL] So 1 in 5.
[AGENT][NEUTRAL] That's all under major.
[CUSTOMER][NEUTRAL] Typically, but
[CUSTOMER][NEUTRAL] So with it with the frequency would be 1 and 5?
[AGENT][NEUTRAL] Well, major is not covered on this policy, so uh it doesn't show me the frequency.
[CUSTOMER][NEUTRAL] Oh, yeah.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] Um, are there any downgrades, uh, to, uh.
[CUSTOMER][NEUTRAL] Cast for metal restorations.
[AGENT][NEUTRAL] Um, no, ma'am, no downgrades.
[CUSTOMER][NEUTRAL] Um, downgrades to.
[CUSTOMER][NEUTRAL] I can never say that word to the filling the M.
[AGENT][NEUTRAL] Um, let me see, I don't believe there is.
[AGENT][NEUTRAL] The um what is it, the Alegram? I hope I'm saying that right.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Uh, no, ma'am. There's no downgrade.
[CUSTOMER][NEUTRAL] OK, and then is there a predetermination mandatory?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK and.
[CUSTOMER][NEUTRAL] OK, let's submit wait a minute, no.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] All right, I got it in. Thank you so much.
[AGENT][POSITIVE] You're welcome. Was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] Uh, no, ma'am.
[AGENT][POSITIVE] Alright, well, thanks for calling APL. I hope you have a great weekend.
[CUSTOMER][NEGATIVE] You too dear.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Mhm bye bye.