AccountId: 011433970860
ContactId: 447d8cb8-b0a2-4b49-9650-5d52ae522567
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1229839 ms
Total Talk Time (AGENT): 426614 ms
Total Talk Time (CUSTOMER): 325632 ms
Interruptions: 1
Overall Sentiment: AGENT=-0.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/21/447d8cb8-b0a2-4b49-9650-5d52ae522567_20250321T20:08_UTC.wav
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[AGENT][POSITIVE] Thank you for contacting ATO. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes ma'am, I was calling to check on eligibility and get a full breakdown for a patient of ours.
[AGENT][NEUTRAL] I can help with the eligibility and benefits, with whom am I speaking, please?
[CUSTOMER][NEUTRAL] Yes, my name's [PII].
[AGENT][NEUTRAL] [PII], thank you. What's that policy number that we're looking at today?
[CUSTOMER][NEUTRAL] I have 02579705.
[AGENT][NEUTRAL] Thank you. And the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] [PII] and date of birth is [PII].
[AGENT][POSITIVE] I do appreciate that. Is there a callback number I can have in the event that we're disconnected?
[CUSTOMER][NEUTRAL] Yes, that is [PII].
[AGENT][NEUTRAL] Thank you. The policy went into effect on [PII]. It is active. Now, these policies have a $1500 per calendar year maximum. Uh, that's just a verification of the benefits, not a guarantee of payment. That covers basic, basic restorative and preventative services right now. Now there is a uh 12 month waiting period for major services, but, um, those will be available uh on [PII].
[AGENT][NEUTRAL] I have a fax back that I can send to you if you would be interested, um, or if there's anything in particular that I could tell you about the policy.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Let me, I will definitely take the fax, but can I go ahead and just get information over the phone?
[AGENT][POSITIVE] Yes, of course.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so you said major services have that 12 month waiting period. What's the percentage of coverage on this?
[AGENT][NEUTRAL] When the major services will be available, that's 40% of the UCR.
[AGENT][NEUTRAL] Um, for basic, basic and basic restorative, it's 80% of UCR.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the preventative services.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, 100% UCR.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, what about periodontics are those basic?
[AGENT][NEUTRAL] That would be uh under uh major services which will be available next year.
[CUSTOMER][NEUTRAL] Major.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, is perio maintenance also considered major?
[AGENT][NEUTRAL] Yes, it is.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And for perio maintenance, um, what's the frequency on that?
[AGENT][NEUTRAL] Let me just check.
[AGENT][NEUTRAL] Do you happen to have a uh
[AGENT][NEUTRAL] CPT code for me that I can.
[CUSTOMER][NEUTRAL] Yes, 4910.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So that's uh has a maximum of 1 procedure for 6 months and that's the same as the regular propy.
[CUSTOMER][NEUTRAL] OK, so it shares frequency.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And then for Idiontics, what does that fall under?
[AGENT][NEUTRAL] That would be under major services at 40% of UCR.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, for
[CUSTOMER][NEUTRAL] Oral surgery, simple and surgical, is that major?
[AGENT][NEUTRAL] The simple extraction, and we cover at 80%, um, and there's no frequency for the major surgery that is uh um at 40%.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] In crowns.
[AGENT][NEUTRAL] Now the crowns and bridges are once every 5 years, and that's under major services.
[AGENT][NEUTRAL] And the partials and dentures are once, uh, excuse me, I'm sorry, [PII], that the crowns and bridges are at 7 years, once every 7 years, and that is a major service. The partials and dentures are once every 5, again a major service.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] 75 for dentures.
[CUSTOMER][NEUTRAL] OK, um, what about inlay and on lay 2630 and 2643.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, this will be under the uh major uh
[AGENT][NEUTRAL] Major services.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the frequency for that, uh,
[AGENT][NEUTRAL] See.
[AGENT][NEUTRAL] That is a maximum of 1 for 7-year period and it's limited to patients [PII] and over.
[CUSTOMER][NEUTRAL] OK. Is there any
[CUSTOMER][NEUTRAL] Implant coverage.
[AGENT][NEUTRAL] No, there is not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, what's the percentage of coverage if there is any for guided tissue 4267?
[AGENT][NEUTRAL] And that will be at 40% and let's see.
[AGENT][NEUTRAL] Just checking.
[AGENT][NEUTRAL] That's it's just at 40%.
[CUSTOMER][NEUTRAL] OK, um, for an oral cancer screen 0431.
[AGENT][NEUTRAL] I don't see that that's covered.
[CUSTOMER][NEUTRAL] OK, what's the time is it, um, is there a cruisal guard coverage?
[AGENT][NEUTRAL] Yes, uh, that is, uh, that is covered, um, let's see.
[AGENT][NEUTRAL] Let me check here.
[AGENT][NEUTRAL] Uh, that is, um, limited to, uh, patients [PII] and over, um, subject to review.
[AGENT][NEUTRAL] And uh
[AGENT][NEUTRAL] It looks like it's a maximum of one per lifetime.
[CUSTOMER][NEUTRAL] OK, is it major?
[AGENT][NEUTRAL] Yes, it is.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, the coverage for bone grafts 7953 and 7950.
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] I'm not sure that that's covered. Let me, let me just check here.
[AGENT][NEUTRAL] I'm not showing that it's covered.
[AGENT][NEUTRAL] I'm still checking. Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm sorry, I don't show that that's covered.
[CUSTOMER][NEUTRAL] OK, that doesn't surprise me. What about 2950 and 2954?
[AGENT][NEUTRAL] 2954 and 2950.
[AGENT][NEUTRAL] OK, let me check.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Excuse me just a moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Honey, I've got to say I'm on the phone. I'm sorry to swear.
[AGENT][NEUTRAL] OK, yes, that is under major services and it's a maximum of 1 for 7-year period and it's limited to patients [PII] and over.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What about
[CUSTOMER][NEUTRAL] A provisional crown 2799.
[AGENT][NEUTRAL] The temporary crown, um, that is the same thing, it's under 40%, um, maximum of 1 for 7-year period and it's limited to patients [PII] and over.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What about 7921 and 7952?
[AGENT][NEUTRAL] OK, you said 7921?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And 79
[CUSTOMER][NEUTRAL] 52.
[AGENT][NEUTRAL] OK, let me just check.
[AGENT][NEUTRAL] OK, I don't show that those are covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is a full mouth debridement covered for 355?
[AGENT][NEUTRAL] It is, uh, that is under major services.
[CUSTOMER][NEUTRAL] OK, what's the frequency?
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] And I do apologize, uh, [PII], do you mind giving me that CPT code again? There's just
[CUSTOMER][NEUTRAL] Not at all, it's 4355.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, for the full mouth debridement uh under major services, frequency for that is a maximum of 1 each quadrant for 24 months.
[CUSTOMER][NEUTRAL] For a 4355?
[AGENT][NEUTRAL] Well, let me look again. 4355 uh.
[AGENT][NEUTRAL] Let's see, OK, 4355 full mouth debridement to. OK, that's OK.
[AGENT][NEUTRAL] That we have a
[AGENT][NEUTRAL] Maximum of 1 each quadrant for 24 months.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Alright, what about.
[CUSTOMER][NEUTRAL] Does it have coverage for Veneers 2960?
[AGENT][NEGATIVE] Uh, no, it does not.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, what about 424-9 and 4346?
[AGENT][NEUTRAL] The periodontal scaling.
[AGENT][NEUTRAL] That
[CUSTOMER][NEUTRAL] 4249 is Crown length.
[AGENT][NEUTRAL] OK, I'm sorry, 249.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Oh, I see.car tissue. OK, so that's the same thing. Um, this is a maximum of 1 each quadrant for 24 months, and they are under major services.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then the gums on fire 1 4346.
[AGENT][NEUTRAL] 4346.
[AGENT][NEUTRAL] Not showing that yet. I'm still just checking.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEGATIVE] It does not look like that's covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, is IV sedation covered 9239 and 9243?
[AGENT][NEUTRAL] Intravenous sedation 30 minutes, yes, it's gonna be under.
[AGENT][NEUTRAL] Uh, major coverage and let me just check here.
[AGENT][NEUTRAL] That is uh only in conjunction with listed complex oral surgery procedures and subject to review.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What about SRPs um 4341?
[AGENT][NEUTRAL] Uh, that is covered and that is a major service, so let's see.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] That is uh
[AGENT][NEUTRAL] Also, um,
[AGENT][NEUTRAL] A maximum of 1 each quadrant for 24 months.
[CUSTOMER][NEUTRAL] OK, can you do 4 quads the same day?
[AGENT][NEUTRAL] Yes, as long as the policy is active and they have available coverage, then yes, all 4 can be done.
[CUSTOMER][NEUTRAL] OK, is there a millimeter pocket depth?
[AGENT][NEUTRAL] No, there is not.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, what about 9110 and 9310?
[AGENT][NEUTRAL] 9110 is under um.
[AGENT][NEUTRAL] Uh, the, um,
[AGENT][NEUTRAL] Basic services, uh, there's no, uh, there's no maximum or limitation on that. And then um 9310 is the same, uh there's no limitation that's under basic services at 80% of UCR.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, let me get, is there any ortho coverage?
[AGENT][NEUTRAL] No, there's not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And OK, so for a limited exam a 0140, what's the frequency?
[AGENT][NEUTRAL] The, uh, the, the oral examinations and they all share the same frequency, uh, that is 2 for 12 month period.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Let's see, can they do treatment the same day?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And 2 for the regular exams.
[CUSTOMER][NEUTRAL] What about bite wings? What's the frequency on that? 0274.
[AGENT][NEUTRAL] That's once for 12 month period.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then for full mouth X-ray or pan the 02 10 and 03.
[AGENT][NEUTRAL] It's once every 5.
[AGENT][NEUTRAL] Yeah, those both were 1, 23 5. Mhm.
[CUSTOMER][NEUTRAL] Once every 5 years.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, is there any frequency on periapical 0220?
[AGENT][NEUTRAL] No, I don't show any frequency on that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, what's the frequency on fluoride?
[AGENT][NEUTRAL] So the frequency for that is um
[AGENT][NEUTRAL] That is limited to children 14 and under or adults 19 and under, and it's the maximum of 1 procedure for
[AGENT][NEUTRAL] 24 months.
[CUSTOMER][NEUTRAL] And what was that age limit again?
[AGENT][NEUTRAL] 14 and under for children, or 19 and under for adults.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And what about frequency for sealants 1351.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] That is once every 36 months, and the coverage is limited to 14 and under.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, do any of the X-rays fall under basic services just to make sure.
[AGENT][NEGATIVE] Yes, uh, the, um, uh, including the full, the, uh, full mouth and panel, uh, they all fall under the, uh, uh, um, basic surfaces.
[CUSTOMER][NEUTRAL] OK, do the periapicals fall under basic?
[AGENT][NEGATIVE] Uh no, they do not.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And neither do the bite wings, right?
[AGENT][NEUTRAL] Uh, the bite wings do, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And does the patient have any history?
[AGENT][NEUTRAL] No, they just got this policy uh earlier last month and so we don't have any history for them at all. So everything, all of the, the basic services would be available.
[CUSTOMER][POSITIVE] OK perfect.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And then you did you say there's not a missing tooth cloth with this plan?
[AGENT][NEUTRAL] There is a missing tooth clause, yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] But there's there there's no ortho coverage and there's no implant coverage.
[CUSTOMER][NEUTRAL] OK, and do you guys pay on prep or seat date?
[AGENT][NEUTRAL] Either of those two dates.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] What's the replacement frequency on fillings?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] So that is um.
[AGENT][NEGATIVE] Only even placed for 24 months and it's 1 each too for 24 months.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And do you guys downgrade on crowns or composites?
[AGENT][NEGATIVE] Uh, no, we do not.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, do preventative services go towards the max?
[AGENT][NEUTRAL] Not the preventative services uh they go towards the maximum, but there's no, uh, the deductible is not taken on that. Now there is a $50 deductible that does not apply to the preventative services, but all the services go towards the maximum.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then $50 deductible.
[CUSTOMER][NEUTRAL] Is there a family deductible?
[AGENT][NEUTRAL] It's $150.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, and that was all I needed if I can just get a reference number.
[AGENT][NEUTRAL] My name is [PII]. The first letter of my last name is [PII], and we're gonna use that in today's date as a reference.
[CUSTOMER][POSITIVE] Alright thank you [PII].
[AGENT][NEUTRAL] OK, there's anything else to help with, thanks for contacting.