AccountId: 011433970860
ContactId: 377d1651-e995-4cf9-b27e-b1cbbccb6081
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 465279 ms
Total Talk Time (AGENT): 242896 ms
Total Talk Time (CUSTOMER): 126902 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/13/377d1651-e995-4cf9-b27e-b1cbbccb6081_20250313T21:14_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], I'm trying to uh verify dental insurance for a patient.
[AGENT][NEUTRAL] Oh, we're just needing to check eligibility.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Sure, I can check that for you. What was your name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, [PII], can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you and then do you have the policy number?
[CUSTOMER][NEUTRAL] I believe that it's 02579735.
[AGENT][NEUTRAL] OK, thank you and what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] OK, uh, the name for the insured is [PII].
[CUSTOMER][NEUTRAL] [PII] and then [PII] so I'm calling for patient [PII].
[AGENT][NEUTRAL] [PII], OK, do you have [PII]'s date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. OK, I appreciate you verifying that. Uh, so this policy is active. Effective date was [PII], and if you'd like, I can send you the fax back that shows all of the covered procedures and benefit information.
[CUSTOMER][NEUTRAL] I would like that, but I do have some questions just because I'm not familiar with this policy, um, um, or would we be considered in network or out of network?
[AGENT][NEUTRAL] Of course, sure.
[AGENT][NEUTRAL] So this policy uh goes off of UCR, not any sort of network um it just pays a percentage based off of UCR.
[CUSTOMER][NEUTRAL] OK, so it's not in or out of network. Alright, is there a group name or number?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, give me just a moment.
[AGENT][NEUTRAL] The group number is 26734.
[AGENT][NEUTRAL] And then the group name is.
[CUSTOMER][NEUTRAL] 26734
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] your name is [PII].
[AGENT][NEUTRAL] Trucking
[AGENT][NEUTRAL] Evergreen
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then um the claims address?
[AGENT][NEUTRAL] Yes, so, uh, we have a mailing address, fax number, and a pair ID. So our, uh, mailing address is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] OK, and the payer ID?
[AGENT][NEUTRAL] The ID is 60801.
[CUSTOMER][NEUTRAL] 60801.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, and does this plan renew every [PII] or on the effective date?
[AGENT][NEUTRAL] Yes, it is a calendar year, yes.
[CUSTOMER][NEUTRAL] OK, is there an annual deductible?
[AGENT][NEUTRAL] Yes, $50 deductible, uh, does not apply to preventative services, but it's $50 per covered insured up to $150 per family.
[CUSTOMER][NEUTRAL] OK, anything you used for [PII]?
[AGENT][NEUTRAL] Let me take a look. Give me just a moment.
[AGENT][NEUTRAL] So none has been used so far this year.
[CUSTOMER][NEUTRAL] And her annual max?
[AGENT][NEUTRAL] The annual maximum for this plan is $1500.
[CUSTOMER][NEUTRAL] They're missing two calls or waiting period?
[AGENT][NEUTRAL] There is a missing teeth cloth, uh, waiting period of 12 months applies to all major expenses, including endodontic and oral surgery and periodontic.
[CUSTOMER][NEUTRAL] OK, what about simple extractions?
[AGENT][NEUTRAL] Um, was that, did you have a specific procedure code for that?
[CUSTOMER][NEUTRAL] Yes, it's D 7140.
[AGENT][NEUTRAL] OK, give me just a moment.
[AGENT][NEUTRAL] So that 7140 is covered under a basic, so at 80%, yes, yes.
[CUSTOMER][NEUTRAL] Is that 80%? OK.
[CUSTOMER][NEUTRAL] Alright and then um are implants covered?
[AGENT][NEUTRAL] No, um, implant placement removal, all related services are not covered.
[CUSTOMER][NEUTRAL] OK, what's the replacement cost for Crowns Bridges dentures D 2740?
[AGENT][NEUTRAL] That is covered under major, so that would be 40%. OK give me just a moment, let me look at those limitations.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] So a maximum of 1 per 7-year period and limited to patients age [PII] and over.
[CUSTOMER][NEUTRAL] Is that seat date or prep date?
[AGENT][NEUTRAL] Either one
[CUSTOMER][NEUTRAL] OK, and for the [PII] do you downgrade on those?
[AGENT][NEGATIVE] None of them have downgrades.
[CUSTOMER][NEUTRAL] What are the timely limit timely file limit for claims?
[AGENT][NEGATIVE] There is no timely filing limit.
[CUSTOMER][NEUTRAL] You said there's not any?
[AGENT][NEUTRAL] Correct, there's only a limit if there were to be uh an appeal.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] What about claims? Do all exempt, I mean, uh, frequency for exams. Do all exempt share?
[AGENT][NEUTRAL] Um, let's see, you mean for, um, like profies and cleaning?
[AGENT][NEUTRAL] Of regular exams.
[CUSTOMER][NEUTRAL] Yeah, for like the, like the, yeah, for like the period exam and the limited exam, do they share? Yes.
[AGENT][NEUTRAL] The frequencies I got you um oh those codes sorry yes I understand what you're saying um.
[CUSTOMER][NEUTRAL] Mhm, no, that's OK.
[AGENT][NEUTRAL] I was looking at frequencies. OK, so that's like uh 0120, right?
[CUSTOMER][NEUTRAL] Yes, in 0140.
[AGENT][NEUTRAL] Got it. OK, yes, they do share, um, 12,001,401,500,160 and 0180.
[AGENT][NEUTRAL] And that is uh
[CUSTOMER][NEUTRAL] OK, and what's the frequency?
[AGENT][NEUTRAL] Yes, 2, evaluations in any of those combinations, uh, per 12 month period.
[CUSTOMER][NEUTRAL] Does it have to be 6 months apart?
[AGENT][NEUTRAL] Not necessarily, no, just 2 per 12 month period.
[CUSTOMER][NEUTRAL] OK, what about proofy?
[AGENT][NEUTRAL] Let's take a look there.
[AGENT][NEUTRAL] I believe that one is, uh, yes, once every 6 months.
[CUSTOMER][NEUTRAL] What about um
[CUSTOMER][NEUTRAL] Right wing X-rays.
[AGENT][NEUTRAL] By wings are once per 12 month period, and then, um, full mouth X-rays and panoramics are once every 5 years.
[CUSTOMER][NEUTRAL] OK, is that preventative?
[AGENT][NEUTRAL] Preventative pays at 100%.
[CUSTOMER][NEUTRAL] OK, and then um the scaling your root planning?
[AGENT][NEUTRAL] Um, what code was that? I'm sorry.
[CUSTOMER][NEUTRAL] 0 4341.
[AGENT][NEUTRAL] Thank you, um, so that is covered under periodontic, so that is at 40%, and give me just a moment, let me take a look at this limitation.
[AGENT][NEUTRAL] That is a maximum of 1 each quadrant per 24 months.
[CUSTOMER][NEUTRAL] All 4 quads allowed the same day?
[AGENT][POSITIVE] Absolutely, yes.
[CUSTOMER][NEUTRAL] OK, and preventative is that 100% right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, and tell me your name again.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And you'll be able to send me the fax?
[AGENT][POSITIVE] Absolutely, what was that fax number for you?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, I'm gonna read that back to make sure I heard that correctly. That was [PII]?
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] Alright, I will get that sent now. It should get it here within 10 to 15 minutes. Was there anything else I can help you with, [PII]?
[CUSTOMER][POSITIVE] No, that'll be all. I appreciate your help.
[AGENT][POSITIVE] Alright, yeah, thanks for calling APL. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you, bye bye