AccountId: 011433970860
ContactId: 3b39bcfb-e0f8-4abf-adba-59173533525e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1390000 ms
Total Talk Time (AGENT): 474030 ms
Total Talk Time (CUSTOMER): 244550 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/19/3b39bcfb-e0f8-4abf-adba-59173533525e_20250319T15:55_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling on behalf of dental office to check an eligibility benefit for patient recorded line. Can you please help me with that?
[AGENT][POSITIVE] I can assist you with the eligibility and benefits, Miss [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] It's [PII] a direct line?
[AGENT][NEUTRAL] Thank you and may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Sure. It's 02574652.
[AGENT][NEUTRAL] Thank you one moment let me pull this information.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Sure. Patient name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, you said you need eligibility and benefits. You need this information given to you verbally or faxed over to you?
[CUSTOMER][NEUTRAL] Verbally?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You have a specific questions or you need a full breakdown?
[CUSTOMER][NEUTRAL] I need the full breakdown.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, before I give you any benefit information, I need to let you know that this is not a guarantee of payment, just a verification of coverage and that's just a disclaimer.
[AGENT][NEUTRAL] And with this um policy, we have a calendar year maximum of $1500 with the $50 deductible and deductible does not apply to preventative.
[AGENT][NEUTRAL] Preventatives cover 100%. Radiograph FMX is covered at 80%, basic expense and basic restorative expenses cover at 80%.
[AGENT][NEUTRAL] And we have major, major risk cover at 40%. This includes endodontics, periodontics, prosthodontic repair and oral surgery. Now, there is a 12 month waiting period for any major service, and the effective date was [PII].
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] And also just to confirm here, what is the fee schedule?
[AGENT][NEGATIVE] We pay under usuring customer rates.
[CUSTOMER][NEUTRAL] All right. May I also have the group name?
[AGENT][NEUTRAL] The name sure, um, let me get that for you one moment.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, this is Group Universal Trucking Anderson Flatbed.
[CUSTOMER][NEUTRAL] Universal trucking, right?
[AGENT][NEUTRAL] Yes, Universal Trucking, Anderson flatbed.
[CUSTOMER][NEUTRAL] Anderson Flat wet, is that right?
[AGENT][POSITIVE] Mhm. Correct.
[CUSTOMER][NEUTRAL] What about group number?
[AGENT][NEUTRAL] That is 14564.
[CUSTOMER][NEUTRAL] Thank you. Also, just to confirm your coordination benefits standard, right?
[AGENT][NEUTRAL] Mm
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] All right. Any missing tooth cloth, any waiting period?
[AGENT][NEUTRAL] Um, there is a missing tooth clause and there is a 12 month waiting period for any major service.
[CUSTOMER][NEUTRAL] Oh yes. All right. And uh has anything been used submit from the annual maximum deductible?
[AGENT][NEUTRAL] I can check one moment.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] OK, for Prince, he has, he has not used his benefit for [PII] as of today, so he still has the full amount available.
[CUSTOMER][NEUTRAL] Or is it covered here?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Alright, so, and you said deductible only applies for basic major, right?
[AGENT][NEUTRAL] Deductibles apply for basic and major and radiograph FMX.
[CUSTOMER][POSITIVE] Alright, thank you so much for that. Also, may I have the frequency on preventive services?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Um, for the frequency, we have cleaning profits once every 6 months. Exams are 2 for 12 month period. By wings are 1 for 12 month period.
[AGENT][NEUTRAL] And then for the radiograph FMX it's gonna be once every 5 years for full mouth X-rays or panels.
[CUSTOMER][NEUTRAL] Alright, uh, what about fluoride? Fluoride is also 1 to 6 months, right?
[AGENT][NEUTRAL] Uh, fluoride it does have, uh, let me see, an age limitation, one moment.
[AGENT][NEUTRAL] Mm OK. It's maximum of 1 procedure for 12 months limited to dependent children under the age of [PII]?
[CUSTOMER][NEUTRAL] [PII]. What about space maintainer and sealants, are they covered?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Clans has an age limitation of um dependent children under the age of [PII] and it's gonna be um the application made to the permanent molar teeth only maximum of 1 procedure for 36 months.
[AGENT][NEUTRAL] And you said you need um space maintainers, what is the code for that one?
[CUSTOMER][NEUTRAL] placement
[CUSTOMER][NEUTRAL] It's 1510.
[AGENT][NEUTRAL] 1510.
[AGENT][NEUTRAL] OK, so let me check the limitation on that one.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Limited to dependent children under the age of [PII] and its maximum 1 per lifetime per quart or arch.
[CUSTOMER][NEUTRAL] All right, one per lifetime. And uh for crowds and fillings any downgrades?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] There's no downgrades.
[CUSTOMER][NEUTRAL] What is the frequency on crowns and fillings?
[AGENT][NEUTRAL] Mm mhm.
[AGENT][NEUTRAL] So for the crowns, it's going to be, let's see, once every 7 years per tooth.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the fillings is
[AGENT][NEUTRAL] Replace the system is in place for 24 months.
[CUSTOMER][NEUTRAL] 24 months. All right. So I have some quotes here. Uh, I have 8 quotes. I just need frequency, shall I give to you all at once?
[AGENT][NEUTRAL] No, one by one.
[CUSTOMER][NEUTRAL] All right, sure. I'll do 2929.
[AGENT][NEGATIVE] 2929 is not covered.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] And then 2930?
[AGENT][NEUTRAL] 2930.
[AGENT][NEUTRAL] That's after the 12 month waiting period and that's going to be.
[AGENT][NEUTRAL] Maximum of 17 year period.
[CUSTOMER][NEUTRAL] All right. 2932.
[AGENT][NEUTRAL] OK, 2932. That's also gonna be after the 12 month waiting period and it's the same.
[AGENT][NEUTRAL] Once in 7 years.
[CUSTOMER][NEUTRAL] 2933.
[AGENT][NEUTRAL] OK, for this one it's the same.
[AGENT][NEUTRAL] It's gonna be the same. So once every 7 years and you know, mhm.
[CUSTOMER][NEUTRAL] Same.
[AGENT][NEUTRAL] After the 12 month waiting period.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] 2934.
[AGENT][NEGATIVE] 2934 is not covered.
[CUSTOMER][NEUTRAL] All right. 9248.
[AGENT][NEUTRAL] 9248 is not covered.
[CUSTOMER][NEUTRAL] Right. And then uh 9230.
[AGENT][NEUTRAL] 9230, that's anesthesia. That's gonna be after the 12 month waiting period. There's no limitation on that one.
[CUSTOMER][NEUTRAL] Covered under the basic major.
[AGENT][NEUTRAL] Major after the 12 month waiting period.
[CUSTOMER][NEUTRAL] All right. 9310.
[AGENT][NEUTRAL] 93.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 9310, that's going to be under basic.
[AGENT][NEUTRAL] And there's no limitation on that one.
[CUSTOMER][NEUTRAL] All right. Thank you. Uh, any history for this patient that might affect frequency?
[AGENT][NEUTRAL] Let me check one moment.
[AGENT][NEUTRAL] There's no history on file for [PII].
[CUSTOMER][NEUTRAL] All right then.
[CUSTOMER][POSITIVE] All right, great. Thank you so much for that. So I do have another uh patient. I just need to ask you a question and you can send a fax back. Can you also help me with that?
[AGENT][NEUTRAL] For this one or for another one?
[CUSTOMER][NEUTRAL] For another one.
[AGENT][NEUTRAL] OK, um, let me make a note on this one, Ms. [PII].
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] What's the next policy number?
[CUSTOMER][NEUTRAL] Sure. The policy number is 2344896.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Sure. Patient name is [PII], date of birth, [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And what questions do you have on this one?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, free schedule here.
[CUSTOMER][NEUTRAL] What is the fee schedule?
[AGENT][NEUTRAL] It's, it's gonna be you showing customer rate the same as the other one.
[CUSTOMER][POSITIVE] Alright, thank you so much.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the group name?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so this one is Universal Trucking Wall Street Systems.
[CUSTOMER][NEUTRAL] And group number?
[AGENT][NEUTRAL] That's 13003.
[CUSTOMER][POSITIVE] Thank you. May I also have the effective date?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Effective date is [PII] and it is active.
[CUSTOMER][NEUTRAL] All right, [PII] runs on calendar year plan coordination benefit standard, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] What about annual maximum deductible?
[AGENT][NEUTRAL] It's gonna be the same as the previous one which is $1550 deductible and the deductible does not apply to preventative.
[CUSTOMER][NEUTRAL] And has anything been met?
[AGENT][NEUTRAL] I can check on it.
[AGENT][NEUTRAL] OK, no, he has not used his benefits for [PII] as of today.
[CUSTOMER][NEUTRAL] All right. And any missing class, any waiting period?
[AGENT][NEUTRAL] There is a missing tooth class. Um, let me see when this one started. There is a 12 month waiting period for any major service. It looks like you're already out of the waiting period.
[CUSTOMER][NEUTRAL] All right. And also is also not covered here, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] All right. So, on the fact pack, is there any um history?
[AGENT][NEUTRAL] No, there's no history on the fax.
[CUSTOMER][NEUTRAL] Uh, can we do the history of the call?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it looks like uh.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let me go back because um I'm just gonna give you everything because it's not, I don't see anything um.
[AGENT][NEUTRAL] Preventative wise, uh, let me see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. So, um, I'm just gonna go down the line, um, but these are not, they're not covered, so they were not covered. Um, but I got a core build up, um, 220.
[AGENT][NEUTRAL] Another one for 218.
[AGENT][NEUTRAL] Another 1423.
[AGENT][NEUTRAL] Another 1 for 21.
[AGENT][NEUTRAL] Another one for 220.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um, another one for tooth 18, another one for tooth 3, another one for tooth 1.
[AGENT][NEUTRAL] These were all done on [PII].
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Any others apart from that?
[AGENT][NEUTRAL] Yeah, I'm trying to find one that we may have covered.
[AGENT][NEGATIVE] I don't see anything here that we may have covered.
[AGENT][NEUTRAL] I have a bite wing um on [PII].
[AGENT][NEUTRAL] An evaluation on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] One moment, it's just that they submitted more than one claim for the same thing, so I have to pull all of them.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Oh yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Looks like that's the only two that I see that it was paid.
[CUSTOMER][POSITIVE] All right. OK, great.
[CUSTOMER][POSITIVE] So thank you so much for helping me today. You have a nice day ahead. Bye-bye.
[AGENT][NEUTRAL] Mm. You're welcome, Miss [PII]. Do you still need that fax back?
[CUSTOMER][POSITIVE] Oh, yes, I'm so sorry. So, uh, whenever you're ready for the fax number.
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] Go ahead, go ahead with the fax number.
[CUSTOMER][NEUTRAL] Already?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The fax number is [PII].
[AGENT][NEUTRAL] OK. Uh do you mind holding for me while I send this out to you right now?
[CUSTOMER][NEUTRAL] Sure, sure. Sure.
[AGENT][NEUTRAL] OK, and that's [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for you, Ms. [PII]. OK, I went ahead and send that over to you. It should be there in a few minutes. Is there anything else I'm gonna help you with today?
[CUSTOMER][POSITIVE] No, this is it. Thank you so much. You have a nice day ahead. Bye-bye.
[AGENT][POSITIVE] You as well. Thank you for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Mm.