AccountId: 011433970860
ContactId: 33fd7c9c-3fd2-4e39-b2da-febf3873ed11
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 633719 ms
Total Talk Time (AGENT): 243870 ms
Total Talk Time (CUSTOMER): 245269 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/33fd7c9c-3fd2-4e39-b2da-febf3873ed11_20250225T22:27_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] Hi [PII], my name is [PII]. I'm calling from a dental office. I'm just trying to verify some benefit information for a patient.
[AGENT][NEUTRAL] OK, well, I can definitely help you with the dental benefits, and [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Uh yeah, my direct line is [PII].
[CUSTOMER][NEUTRAL] And the policy number is 70087.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] Can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh, patient is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, this is a different member. That may be the group number. Um, do you have the member's ID card available?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, sorry, when I heard policy number I thought you meant group number. The ID is uh 258.
[CUSTOMER][NEUTRAL] 093 1.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and I have her here and all the information provided is a verification of benefits, not a guarantee of payment. And what questions did you have in reference to the benefits?
[CUSTOMER][NEUTRAL] Um, so I did speak to a rep, um, already, and she had sent me a fax back, um, but I still haven't gotten it, so I just have a few more questions and then I just, I won't need one at all. um, first, could I just have the, uh, claims address on where to send claims?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, it's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] OK, [PII], [PII].
[CUSTOMER][NEUTRAL] OK and then um.
[CUSTOMER][NEUTRAL] For the preventative services, well, first off, is this a calendar year plan or a benefit calendar? OK, perfect.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And is there any deductible for um like a family deductible or is it just an individual?
[AGENT][NEUTRAL] Um, well, I guess both, so it's 50, it's 50 per person up to 150 per family.
[CUSTOMER][NEUTRAL] OK perfect and then for the preventative and basic services, what is the percentage of coverage for those?
[AGENT][NEUTRAL] 100% for preventative and 80 for basic.
[CUSTOMER][NEUTRAL] OK and then um for exams, um, do all exams share frequency including the limited exams?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, the only exams that share frequency is 001200014050 and 60.
[AGENT][NEUTRAL] Um, and it's 2 for 12-month period.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So then for the limited, which is a 0140, what is the frequency on that?
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] It's the same, it's paired with, so 120, 140, 150 and 60, they're all paired together. So it's 2 per 12 months.
[AGENT][NEUTRAL] At um
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on 1 2nd.
[AGENT][NEUTRAL] The evaluations, hold on.
[AGENT][NEUTRAL] And they're under preventative at 100.
[CUSTOMER][NEUTRAL] OK perfect and then um for palliative care code 9110, is that a covered benefit?
[AGENT][NEUTRAL] 9110.
[AGENT][NEUTRAL] Yes, under basic at 80.
[CUSTOMER][NEUTRAL] OK, and what's the frequency and is treatment allowed on the same day?
[AGENT][NEUTRAL] There's no frequency and no specification, um, so you could use the treatment on the same day.
[CUSTOMER][NEUTRAL] OK and then um for the panoramic and FMX um what is the frequency and do they share frequency?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] FMX and panels, um, is 80% as well once every 5 years, and it's um let me see if that's paired with anything.
[AGENT][NEGATIVE] No, I don't see that it's paired with anything.
[CUSTOMER][NEUTRAL] So like they could have a panoramic and then turn around and have an FMX and both would be paid within the 5 years.
[AGENT][NEUTRAL] Hold on. Well, panels and FMX for us are together.
[CUSTOMER][NEUTRAL] That's what I was asking. Are they, are they under the same frequency? Do they share frequency?
[AGENT][POSITIVE] Yes, it's all together for us, yes.
[CUSTOMER][NEUTRAL] OK, and then, um, does the deductible apply to X-rays?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Well, our X-rays and panels are under basic and
[AGENT][MIXED] Yes, it does. Deductible um applies to everything except preventative.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK perfect and then for um PAs or peri apicals um is there a frequency on those?
[AGENT][NEUTRAL] Now, for that one, do you have a code for that one?
[CUSTOMER][NEUTRAL] Um, a PA is normally a 0220.
[AGENT][NEUTRAL] 0220 is under basic at 80 with no frequency.
[CUSTOMER][NEUTRAL] OK perfect and then for the bite wings um I just need to know if there's a difference in frequency between the adult and child um and then what that frequency is.
[AGENT][NEUTRAL] No, it's the same, um, bite wings are once every 5 years I'm sorry, once per 12 month period.
[CUSTOMER][NEUTRAL] OK, OK, for 12 months. OK, perfect. And then for um profy, um, or cleanings, um, what is the frequency and does that include perio cleanings or are those not covered?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, no major services are covered. Major for us is endodontic, periodontic, proteodontic, and oral surgery.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, but hold on one moment.
[AGENT][NEUTRAL] And the proffe are once every 6 months.
[CUSTOMER][NEUTRAL] OK, and then for fluoride, um, what is the coverage and to what age?
[AGENT][NEUTRAL] So fluoride, CDCG, hold on one second.
[AGENT][NEUTRAL] OK, so fluoride is under preventative at 100%. If it's a child, it's limited to dependent children under age [PII], adult is limited to dependent children aged [PII].
[CUSTOMER][NEUTRAL] OK, help me understand what you mean there.
[AGENT][NEUTRAL] You asked for the age limits if their children are adults?
[CUSTOMER][NEUTRAL] Right, so you're saying you consider them an adult over [PII]?
[AGENT][NEUTRAL] No, for the children, for the child codes, it's limited to dependent children under age [PII], and then for adults, it's limited to dependent children aged [PII] and up.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII], [PII] and up, so it will cover adults then.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So [PII] or [PII] up.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then um.
[CUSTOMER][NEUTRAL] And what was the frequency on it?
[AGENT][NEUTRAL] That is, let me see.
[AGENT][NEUTRAL] See, so it's a maximum of 1 procedure per 12 months.
[CUSTOMER][NEUTRAL] OK, and then, uh, spacers code 1510, uh, what is the coverage on that?
[AGENT][NEUTRAL] 1510.
[AGENT][NEUTRAL] OK, so that's preventative at 100% and
[AGENT][NEUTRAL] Limited to dependent children under age [PII].
[AGENT][NEUTRAL] A maximum of one.
[AGENT][NEUTRAL] Per lifetime, per quadrant, or arch?
[CUSTOMER][NEUTRAL] OK, one per lifetime.
[CUSTOMER][NEUTRAL] OK, and then the last code that I am interested in.
[CUSTOMER][NEUTRAL] Um, is sealants. Um, what is the coverage on those?
[AGENT][NEUTRAL] Seal it
[AGENT][NEUTRAL] Let's see, hold on, see.
[AGENT][NEUTRAL] OK, sealants are preventative at 100%. Let's see. Maximum 1 procedure for 36 months.
[AGENT][NEUTRAL] Limited to dependent children under age [PII]?
[AGENT][NEUTRAL] And applications made to molar teeth only.
[AGENT][NEUTRAL] To permanent molar teeth only.
[CUSTOMER][POSITIVE] OK. Perfect. Permanent molars per perfect. OK. And then um so you said that oral surgery was not covered, but does that include like a limited like a simple extraction?
[AGENT][NEUTRAL] Like a 7140?
[CUSTOMER][NEUTRAL] Or is it only if it's like, right, right.
[AGENT][NEUTRAL] That's under basic and let me see if there's a limitation, a maximum of one time per tooth.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One time for 2, well, yeah, obviously.
[CUSTOMER][POSITIVE] Sounds good. OK, perfect. And then I just need um I think that's everything. I don't see that I have anything else. I just need um your name for a reference.
[AGENT][NEUTRAL] Oh, sure. My name is [PII].
[CUSTOMER][POSITIVE] All right perfect thank you so much for all of your help [PII] have a great rest of your day.
[AGENT][POSITIVE] You're very welcome, [PII]. Well, thanks for calling APL and I hope you have a great day also.
[CUSTOMER][POSITIVE] Yep, thank you. Bye.
[AGENT][POSITIVE] You're welcome. Bye bye.