AccountId: 011433970860
ContactId: 38f489cb-d6ed-482e-8610-a6c38b848043
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 524760 ms
Total Talk Time (AGENT): 264549 ms
Total Talk Time (CUSTOMER): 166824 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/38f489cb-d6ed-482e-8610-a6c38b848043_20250604T17:47_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling ATL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Um, yes ma'am. My name is [PII]. I'm calling from a provider's office and I needed to check to see if we were in network with the patient's plan, please.
[AGENT][NEUTRAL] OK, sure, I can assist you with network information, Ms. [PII], and may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Um, the member ID she gave was 615099.
[AGENT][NEUTRAL] OK let me try that one moment.
[CUSTOMER][NEUTRAL] Doesn't sound like enough characters enough numbers, so I do have her social if needed.
[AGENT][NEUTRAL] It's OK. It may be an old policy.
[AGENT][NEUTRAL] Mhm. May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Name is [PII]
[AGENT][NEUTRAL] What's your date of birth?
[CUSTOMER][NEUTRAL] Date of birth is [PII], so [PII].
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Thank you. And what's the name of the facility you're calling from, Ms. [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. Thank you. All right. So I do have the policy pulled up. That is an old policy, so it is it's short, it's really short, but it is the policy number. Um, with this one, there's no network. We pay flat amounts based on the quotes on this one.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you pay based off the office's UCR fees?
[AGENT][NEUTRAL] No, this one has flat amounts. Um, I can go ahead and send you a breakdown of benefits, schedule of benefits, anyone.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK, um, but, uh, so I'm just not clear, are we in network or out of network?
[AGENT][NEUTRAL] There's no network.
[CUSTOMER][NEUTRAL] No network so it will cover wherever she wants to go.
[AGENT][NEUTRAL] Mm
[AGENT][POSITIVE] Correct. It's just gonna cover the flat fee that is in the schedule benefits instead of a percentage.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But so I'm just a little confused so if we're not contracted um what we have to follow that?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Or it would just be based, they would just cover a certain amount and then the patient would be responsible for the remainder.
[AGENT][NEUTRAL] More than likely, that's how it, yeah, more than likely that's how they usually use it. Um, yeah, it, it really depends on where she goes to because there's places that have discounts, additional discounts or something like that. So we're just gonna pay that flat fee and I guess anything over, yeah, it's gonna be members responsibility. Mhm.
[CUSTOMER][NEUTRAL] Because we would
[CUSTOMER][NEUTRAL] If we're not in contract,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, got it, OK.
[CUSTOMER][NEUTRAL] Got you. OK, I understand. Yes, I would like that fee schedule, um, and can I get the claims address please?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Yes, and it's also gonna be there, but I can go ahead and give it to you. The address.
[CUSTOMER][POSITIVE] Oh OK perfect if it's on there, uh huh go ahead.
[AGENT][NEUTRAL] OK. Um, well, that's [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 50 yeah OK um and then.
[AGENT][NEUTRAL] Yes, and I'm ready for the fax number.
[CUSTOMER][NEUTRAL] OK [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] That's [PII].
[CUSTOMER][POSITIVE] Yes, that's correct, um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is the effective date on that plan on there as well?
[AGENT][NEUTRAL] Yes, the effective date is [PII]. That's also gonna be in the fax bag. The fax pack is really, really detailed, um.
[CUSTOMER][NEUTRAL] OK, you said of this year? [PII]?
[AGENT][NEUTRAL] No, [PII].
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] [PII], got it, sorry.
[AGENT][NEUTRAL] Yeah, it's OK.
[CUSTOMER][NEUTRAL] Um, and I know you said it's very detailed, which is great, but um, does this plan have any frequency limits on things?
[AGENT][NEUTRAL] Um, yeah, there is a frequency limit on, um, some things, um, let me check because.
[AGENT][NEUTRAL] It's a little bit different.
[AGENT][NEUTRAL] Well, the frequency is like um for the oral examination is once every 6 months, um, proffe cleaning is once every 6 months, by wins once every 6 months, and all this is gonna be also on the breakdown of benefits, um, crowns and bridges once every 5 years, partial and dentures once every 5 years, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For your dons once every 3 months, full mile department uh once every 12 months, ginger vital, yeah.
[CUSTOMER][NEUTRAL] OK, so specifically, um, could you give, can you give me history for two different codes, if any?
[AGENT][NEUTRAL] Uh-huh. Sure, yes, uh-huh, go ahead.
[CUSTOMER][NEUTRAL] OK, 0150 and 0330.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, it's gonna be a minute. I'm working on this, um, fax back as well.
[CUSTOMER][POSITIVE] Mhm yeah no worries take your time.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the last oral evaluation, the 00150, um, was on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let's see.
[AGENT][NEUTRAL] I don't see a 330.
[AGENT][NEUTRAL] I think they share frequency with full mouth, so let me check on that one as well.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so, um, I got a full mouth on the same day, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And that's only allowed every 5 years or 60 months you said?
[AGENT][NEUTRAL] Let's see. Once every 3 years.
[CUSTOMER][NEUTRAL] 3 years, OK.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] And so everything is just gonna be a flat fee so no percentages, right?
[AGENT][NEUTRAL] That is correct. It's just a flat fee, um, it's gonna have like the coding and the amount that we pay for each code beside it.
[CUSTOMER][NEUTRAL] Got it and then um is there a deductible on this plan?
[AGENT][NEUTRAL] Yes, and there is a $50 deductible and deductible does not apply to exams or pro fees.
[CUSTOMER][POSITIVE] Just OK, basic and me perfect.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, and a maximum.
[AGENT][NEUTRAL] Um, yes, and this is not a guarantee of payment, just a verification of coverage that's also gonna be on the breakdown and that's 1000 per cover insured.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] 1000
[CUSTOMER][NEUTRAL] And nothing's been met yet.
[AGENT][NEUTRAL] I can check and see.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK. So it looks like she already used $89 this year.
[AGENT][NEUTRAL] And she already met $40 of the $50 deductible. So she has a remaining of $911.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK alright and then just a um.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] A reference number for this call please.
[AGENT][NEUTRAL] OK, we don't have reference numbers. You can use my name in today's date if you will. Do you need the spelling of my name?
[CUSTOMER][NEUTRAL] Is it [PII]?
[AGENT][NEUTRAL] Yes, [PII] last initial [PII]
[CUSTOMER][NEUTRAL] OK, all right.
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thank you so much. All right, thank you for your help.
[AGENT][POSITIVE] You're welcome. No problem. Thank you for calling APO. Have a good day. Bye-bye.
[CUSTOMER][POSITIVE] Thank you bye bye.
[CUSTOMER][POSITIVE] Yes ma'am you too bye bye.
[AGENT][POSITIVE] Thank you