AccountId: 011433970860
ContactId: 3a45ec3b-ff08-4c48-96f2-6453e25295b4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 679049 ms
Total Talk Time (AGENT): 266670 ms
Total Talk Time (CUSTOMER): 224984 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/31/3a45ec3b-ff08-4c48-96f2-6453e25295b4_20250131T17:02_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi and I just had a couple eligibility and um benefits questions oh and I wanted to just see if there was um.
[CUSTOMER][NEUTRAL] Um, someone that's under a policy of a subscriber.
[AGENT][NEUTRAL] Hold on, your phone's breaking in and out. I heard subscriber, I think.
[CUSTOMER][NEUTRAL] Yeah, I just wanted to see if there was a person that was on the same plan as the subscriber.
[AGENT][POSITIVE] OK. Oh, well, I can definitely help you with the eligibility and benefits. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, my name is [PII]
[CUSTOMER][NEUTRAL] And you can call me back at [PII] mhm.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Uh, you can call me back at [PII].
[AGENT][NEUTRAL] Thank you for that and [PII], may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, it's 02554436.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Is it [PII]?
[CUSTOMER][NEUTRAL] And then the date of birth is uh yes.
[AGENT][NEGATIVE] No, no, I'm, I'm listening. It's, it's just breaking up. Go ahead.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh, OK, I'm sorry, it's [PII].
[AGENT][NEUTRAL] OK, so I have two questions. Are you saying [PII] or [PII]?
[CUSTOMER][NEUTRAL] I heard the patient say [PII] or but it must be [PII].
[AGENT][NEUTRAL] We do have it listed as [PII] and then the date of birth, you said [PII]?
[CUSTOMER][NEUTRAL] It's in [PII]
[CUSTOMER][NEUTRAL] Yeah, [PII]. That's the birthday that she gave me I mean.
[AGENT][NEUTRAL] I'll just note it. Maybe it came over differently. I'll just note it. Hold on one moment, 17.
[CUSTOMER][NEUTRAL] Is it a different birthday?
[AGENT][NEUTRAL] OK, so all the information provided is a verification of benefits, not a guarantee of payment, and um you have questions about the the dependent or spouse?
[AGENT][NEUTRAL] Are you OK.
[CUSTOMER][NEUTRAL] Yeah, um, it's her name is [PII]. I'm not sure if if she's a dependent or a spouse. She, she may be a, um, a dependent just because she was born in [PII], so at least I would hope so.
[AGENT][NEUTRAL] What's her, what's her date of birth?
[CUSTOMER][NEUTRAL] Uh, her date of birth is [PII].
[AGENT][NEUTRAL] OK. So yes, I am showing that she's on the dependent on file and then [PII] um is the subscriber.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK perfect um just a couple questions about that, um, so have they used any of their Mac or has a deductible in met?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see, hold on one moment.
[AGENT][NEUTRAL] Um, so they have not met any of the max or um the deductible or used any of the max or met the deductible, sorry.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and does the deductible apply to preventative, basic, or major?
[AGENT][NEGATIVE] It does not apply to preventative, it applies to basic and major.
[CUSTOMER][NEUTRAL] OK, um, and is there a waiting period?
[AGENT][NEUTRAL] Hold on one moment, I'm pulling up their fax back. Hold on one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And while I'm pulling that up just for the call, all the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment, I'm just waiting for it to come up.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so it just came up, and can you repeat your question for me, please? You said waiting periods.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] So there is a 12-month waiting period from the day the um policy became effective and that was [PII]. So this December, it will be a full year.
[CUSTOMER][NEUTRAL] OK, so no waiting period then, um, is medical billed first for all surgery?
[CUSTOMER][POSITIVE] Well you have a great rest of your day.
[AGENT][NEUTRAL] Say that one more time.
[CUSTOMER][NEUTRAL] Is medical bills first for oral surgery?
[AGENT][NEUTRAL] Um, for this policy, it doesn't matter. Um, however, whenever we receive the claim, we'll go ahead and process it.
[CUSTOMER][NEUTRAL] OK, um, and is this like this is calendar or fiscal.
[AGENT][NEUTRAL] This is calendar.
[CUSTOMER][NEUTRAL] OK, um, is there any history of like um.
[CUSTOMER][NEUTRAL] Full mouth X-rays or bite wing X-rays for Retara.
[AGENT][NEUTRAL] See, hold on one second. We actually haven't processed any claims for her yet, so, um, there's no history on file.
[CUSTOMER][NEUTRAL] Ok great let's see um
[CUSTOMER][NEUTRAL] OK, uh, let's see here. Oh, is there a downgrade for crowns or fillings?
[AGENT][POSITIVE] No, no downgrades.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, could I give you some codes and you just help me with the frequency or percentage because I have the fax back, but it just wasn't clear for me.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, um, and what's the list of codes you have?
[CUSTOMER][NEUTRAL] OK, I have um the 6010.
[CUSTOMER][NEUTRAL] D 6057.
[CUSTOMER][NEUTRAL] 6058.
[CUSTOMER][NEUTRAL] 7140
[CUSTOMER][NEUTRAL] 9243.
[CUSTOMER][NEUTRAL] 9944 um um that's it.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold just to go through this?
[CUSTOMER][POSITIVE] Yeah, that's no problem.
[AGENT][NEUTRAL] OK, hold on one second.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 60.
[AGENT][NEUTRAL] 601. Wait, what? 6010.
[AGENT][NEUTRAL] I don't see that.
[AGENT][NEUTRAL] 6
[AGENT][NEGATIVE] They need to make this uh print uh so you can find it, not an image.
[AGENT][NEUTRAL] 6010, 6010.
[AGENT][NEUTRAL] I don't see that.
[AGENT][NEUTRAL] I don't see that.
[AGENT][NEUTRAL] 60. I really do not see that.
[AGENT][NEUTRAL] 605 7.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I don't see that either. 6058 wasn't on there either. 7140.
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] 27.
[AGENT][NEUTRAL] That might be why she asking cause she ain't see it.
[AGENT][NEUTRAL] 7140.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 7410? No, she said 7140.
[AGENT][NEUTRAL] 2
[AGENT][NEUTRAL] Oh, I see that.
[AGENT][NEUTRAL] 9243.
[AGENT][NEUTRAL] 129243 044.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][POSITIVE] All right, thank you so much for holding. I apologize for the wait. So, I, OK, so I have a question. Are you asking about these clothes because you didn't see them or you saw them and had questions because I didn't see them on this list.
[CUSTOMER][NEUTRAL] OK, interesting, because I, that's probably why I didn't get it because I don't, I was doing this yesterday so I'm just trying to remember why I don't have it filled out, but I probably didn't see them um because Night Guard, I know for sure I didn't see that one. Yeah, OK, so I guess that means that they're not covered like implants and implant crown, is that not covered?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, cause those aren't on that list.
[AGENT][NEUTRAL] Right, so implants, um, hold on, let me go back up to that.
[AGENT][NEGATIVE] Implants, placement, removal and all related services aren't covered. Um, any code that you don't see on the list is in a cover code, but now cra.
[CUSTOMER][NEUTRAL] OK, so removables aren't covered.
[AGENT][NEGATIVE] Removables aren't covered.
[AGENT][NEUTRAL] In terms of implants, yes.
[CUSTOMER][NEGATIVE] Cause I
[CUSTOMER][POSITIVE] OK, because I did see a frequency for that. Hi, welcome in.
[AGENT][NEUTRAL] What code is it?
[CUSTOMER][NEUTRAL] It's 5110.
[CUSTOMER][NEUTRAL] Let me see where I thought that yeah.
[AGENT][NEUTRAL] No, 5110 is on here. Um, so, but under the um
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Under the frequencies on the first page, like, um, and then under the frequencies you'll see like all the limit the exclusions or limitations.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's where I saw the implants at, but I do see that code on there as well.
[CUSTOMER][NEUTRAL] Right, right, OK.
[CUSTOMER][NEUTRAL] OK, um, so I guess, uh, sedation, the guard extra, but I did see 70 to 40 that that was 40% covered, um, but I didn't see 7140, so I guess that one would just be not covered then.
[AGENT][NEUTRAL] Right, but I did see 72 on here too, 7240.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm. Alright, so I guess and that just isn't covered then. Well, that was all that I had. Can I get a reference number for this call?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name and today's date. Um, the first initial to my last name is [PII].
[CUSTOMER][POSITIVE] Alrighty thank you so much.
[AGENT][POSITIVE] You're very welcome, [PII]. I hope you have a great day and thanks for calling APL.
[CUSTOMER][POSITIVE] Yes ma'am, thank you.
[AGENT][POSITIVE] You're welcome. Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.