AccountId: 011433970860
ContactId: 332e6e79-8af8-4589-827e-ae47eac824d5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 515109 ms
Total Talk Time (AGENT): 269288 ms
Total Talk Time (CUSTOMER): 153853 ms
Interruptions: 0
Overall Sentiment: AGENT=1.1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/06/332e6e79-8af8-4589-827e-ae47eac824d5_20250106T20:32_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hi, I'm sorry, what was that? I could barely hear you.
[AGENT][POSITIVE] Oh, I'm so sorry. My name is [PII]
[CUSTOMER][NEUTRAL] Hi, good afternoon, Ms. [PII]. I was just calling because I, I needed help on a patient's breakdown for his insurance.
[AGENT][NEUTRAL] Yeah absolutely so you're looking for um some benefit information?
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] Perfect and can I have, do you mind if I get your name and a good call back number real quick?
[CUSTOMER][NEUTRAL] Yes, uh, first name is [PII]. Phone number is [PII].
[AGENT][NEUTRAL] Thank you. And what is that member's policy number, Ms. [PII]?
[CUSTOMER][NEUTRAL] That is going to be.
[CUSTOMER][NEUTRAL] 01294066
[AGENT][POSITIVE] Perfect.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Your member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] First name is [PII], last name is [PII]. Date of birth is [PII] I'm sorry, [PII].
[AGENT][POSITIVE] Wonderful thank you so much and are you wanting me to go ahead and send you a fax pack of benefits he is current and active?
[CUSTOMER][NEUTRAL] Yes, please, and then I do have a couple questions as well.
[AGENT][POSITIVE] OK, yeah, you bet. Give me one second to get this facts back together and then I can answer any questions you might have.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] My pleasure.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And are you gonna want that made attention to yourself, ma'am?
[CUSTOMER][NEUTRAL] I'm sorry, one more time?
[AGENT][NEUTRAL] Are you gonna want that made attention to yourself?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you. What's that fax number I can send it to?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] Perfect and I'm hitting, oh hold on, let me read this back [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, I'm hitting send on that now, Miss [PII], and it should be coming your way. And then what questions can I help you with about him?
[CUSTOMER][NEUTRAL] Um, on this, do you mind checking if my doctor's in work with that type of plan?
[AGENT][NEUTRAL] Oh, OK, so this plan doesn't have a network we're gonna honor coverage anywhere that fax back will have the schedule of services.
[CUSTOMER][NEUTRAL] Oh OK, OK. And then um for preventative and diagnostics, does the max apply to that?
[AGENT][NEUTRAL] Um, yes, so as far as like their max benefit, it will, um, apply the preventative and diagnostic, um, but the preventative will be, um, will not apply to their deductibles, so they won't have to pay towards their deductible for preventative expenses.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then is there a waiting period on the plan?
[AGENT][NEUTRAL] Um, for all of their major expenses, NDO, I cannot pronounce any of these words, ma'am. I'm so sorry. Endo and Perry and oral surgery expenses all have a 12 month waiting period, but your patient has been active with us since [PII], so he is past all of those.
[CUSTOMER][NEUTRAL] It's OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Thank you. And then, do any of these quotes share frequency?
[AGENT][NEUTRAL] Oh, OK, yes. So let me go back here real quick.
[AGENT][NEUTRAL] So it looks like 120140150 160 and 180 are all gonna share a frequency which is limited to two oral evaluation procedures in any combination per 12 month period.
[AGENT][NEUTRAL] And then you also have, let me know if I'm going too fast, but you also have 270272 and 274 sharing the frequency as limited to one bite wing X-ray procedure for 12 month period.
[AGENT][NEUTRAL] And then I have one more set and that's it. It's gonna be 210277.
[CUSTOMER][NEUTRAL] Yeah just show
[AGENT][NEUTRAL] 3:30 um are all gonna share a frequency which is limited to one X-ray procedure for 5 year period.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you want me to see if he's had any of those for like the those ones that are limited?
[CUSTOMER][NEUTRAL] And then for the call.
[CUSTOMER][NEUTRAL] Um, no, it's OK, um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] On the code 11:10, would that share the frequency with the code 4910?
[CUSTOMER][NEUTRAL] I think what they did they did.
[CUSTOMER][NEUTRAL] location with the cleaning and everything.
[AGENT][NEUTRAL] Um, no, the only limit I cannot talk. I'm so sorry. The only limitation on 11:10 is a maximum of 1 procedure for 6 months.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, and then.
[CUSTOMER][NEUTRAL] Would there be any pre-authorizations required on the plan?
[AGENT][NEGATIVE] I do not believe any pre-authorization is required for this plan.
[CUSTOMER][NEUTRAL] OK, and then for fillings to those downgrade?
[AGENT][NEUTRAL] We don't do downgrades, I'm sorry.
[CUSTOMER][NEUTRAL] OK. And then for oral surgery, is that paid by dental or medical?
[AGENT][NEUTRAL] Um, we do have, uh, we do cover 40% of the oral surgery expense, uh, 40% of the UCR. Um, I'm not sure if
[AGENT][NEUTRAL] You can I actually, I don't really know it doesn't say on here you can't build dental, so I don't really know how that works or if you like bill it out to both places.
[CUSTOMER][NEUTRAL] OK, and that's fine um and then for the code 4341 which is gonna be the.
[CUSTOMER][NEUTRAL] The deep cleaning, um, can all four quads be done on the same day?
[AGENT][NEUTRAL] Um, see, 4341 you said, right?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Um, it looks like all 4 can be done on the same day because the only limitation is 1 quadrant each or 1.
[AGENT][NEUTRAL] I can't I'm so sorry. I don't know what it is, why I can't read today. Maximum of 1 each quadrant per 24 months, so it looks like the quadrant itself is limited to once every 24 months, but not the different quadrants being done on the same day. I don't know if that makes sense.
[CUSTOMER][NEUTRAL] Yes, yes, yes, OK, and then is there a missing tooth cloth?
[AGENT][NEUTRAL] Um, I believe there is, but let me scroll back up and double check.
[AGENT][NEGATIVE] Yes, there is a missing tooth cloth.
[CUSTOMER][NEUTRAL] OK, and then for the last question is gonna be crowns, are those paid on prep or C?
[AGENT][NEUTRAL] OK, so we don't have any specifics.
[AGENT][NEUTRAL] Um, we'll pay on either, just not both.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, and do you mind just providing me with the claim address?
[AGENT][NEUTRAL] Yeah, absolutely, um, claims are gonna wanna go to [PII].
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] I do wanna let you know, um, Ms. [PII], that any benefit information I give over the phone today is just a verification of coverage and never guarantee a payment.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, yes ma'am, that is fine, thank you very much and then um do you mind repeating the zip code one more time?
[AGENT][NEUTRAL] Yes, um, the zip code here is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII] OK and then that will be it. Can I just get a reference number for the call?
[AGENT][NEUTRAL] Yes, absolutely. Our reference number is going to be my name, [PII], first initial last name, [PII], in today's date.
[CUSTOMER][POSITIVE] Alrighty then thank you very much that will be it for today.
[AGENT][POSITIVE] Yes my pleasure thank you so much for calling APL. I hope you have a fabulous day.
[CUSTOMER][POSITIVE] Thank you as well.
[AGENT][POSITIVE] Thanks, bye.
[CUSTOMER][NEUTRAL] Bye bye.