AccountId: 011433970860
ContactId: 45085445-44f3-4a6e-a96b-82b4ed3c2a75
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 511790 ms
Total Talk Time (AGENT): 243315 ms
Total Talk Time (CUSTOMER): 146243 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/22/45085445-44f3-4a6e-a96b-82b4ed3c2a75_20250422T17:42_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling ATL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hey, um, I'm calling from a provider's office to check on a patient's out of network benefits.
[AGENT][POSITIVE] OK, sure, I can assist you with benefits. And may I have your name?
[CUSTOMER][NEUTRAL] Yes, this is [PII].
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] And may I have a callback number just in case we get disconnected Miss [PII]?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] Thank you and may I have the name of the facility you're calling from from my notation?
[CUSTOMER][NEUTRAL] Yes, Southeastern Dental Center.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Let me see, it is 02612730.
[AGENT][NEUTRAL] OK. May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yes, it's
[CUSTOMER][NEUTRAL] Uh, I'm gonna spell it. [PII] Last name is [PII].
[CUSTOMER][NEUTRAL] Um, date of birth is [PII].
[AGENT][NEUTRAL] OK, perfect. Thank you. All right, and Ms. [PII], you said you need outpatient benefits um or out of network, not outpatient.
[AGENT][NEUTRAL] Um, and this particular policy has an effective date of [PII]. It, it is active. Uh, this is one of our basic dental policies, and there is no network. So we pay on the usual and customary rate, um, unless the provider participates with Carrington, which is not required.
[CUSTOMER][NEUTRAL] So is it like a fee schedule or you guys paying?
[AGENT][NEUTRAL] Percentages.
[CUSTOMER][NEUTRAL] Like normally
[AGENT][NEUTRAL] Normal.
[AGENT][NEUTRAL] Yes, do you need a fax back on benefits?
[CUSTOMER][NEUTRAL] OK, um, what.
[CUSTOMER][NEUTRAL] Yeah, I just have a couple of questions about their policy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, go ahead.
[CUSTOMER][NEUTRAL] Hello
[CUSTOMER][NEUTRAL] Do you guys pay the provider or the patient?
[AGENT][NEUTRAL] The provider.
[CUSTOMER][NEUTRAL] Provider, OK and then what is um the name of the plan is that group voluntary dental?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mrs. 3 Carrington.
[AGENT][NEUTRAL] APL.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But I just wanna make sure it's not through Carrington.
[AGENT][NEUTRAL] It's not too Carrington.
[CUSTOMER][NEUTRAL] Because it also said
[AGENT][NEUTRAL] Mhm. Yeah, it's not through Carrington, it's APL. Now, if the provider participates with Carrington, they can use their PPO schedule um for benefits, but it is through APL.
[CUSTOMER][NEUTRAL] OK, and the group number is 70056?
[AGENT][NEUTRAL] Let me double check.
[AGENT][POSITIVE] Yes, that is correct. Mhm.
[CUSTOMER][NEUTRAL] OK, and then coordination of benefits, is that standard or non duplicating?
[AGENT][NEUTRAL] We don't coordinate.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, has there ever been a waiting period or missing two calls?
[AGENT][NEUTRAL] Not on this one because this one doesn't have any major service. Um, this one is just basic, so it will only cover preventative, radiograph, basic expense and basic restorative only.
[CUSTOMER][NEUTRAL] OK, so no major work like no implants, oral surgery or anything?
[AGENT][NEUTRAL] Um, major includes endodontics, periodontics, prosthodontic repair, or surgery.
[AGENT][NEUTRAL] Though those are not covered.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, is it a calendar year plan?
[AGENT][NEUTRAL] Yes, the calendar year maximum is $500 with the $50 deductible, and this is not a guarantee of payment, just a verification of coverage.
[CUSTOMER][NEUTRAL] OK, is there a family deductible?
[AGENT][NEUTRAL] It's 150 if it's a family plan.
[CUSTOMER][NEUTRAL] OK, and then you said preventative and diagnostic, that's covered at 100%?
[AGENT][NEUTRAL] Preventatives cover 100% and radiograph FMX is covered at 80%.
[CUSTOMER][NEUTRAL] OK, and then D0220 is that two per calendar year?
[AGENT][NEUTRAL] Let me check. You said D 0220?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so that's gonna be basic, uh, that one doesn't have any limitation.
[CUSTOMER][NEUTRAL] OK, so there's no frequency?
[AGENT][NEUTRAL] No, you just pay on their basic.
[CUSTOMER][NEUTRAL] OK, what about you?
[AGENT][NEUTRAL] I'm sorry, go ahead. I didn't, I didn't understand.
[CUSTOMER][NEUTRAL] No, you're fine. Um, what about the 11:10?
[AGENT][NEUTRAL] OK, so that's the pro fee. Uh, the pro fee is going to be once every 6 months and that's pay on the preventative.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, is that the same for D 1206 and D 0274?
[AGENT][NEUTRAL] You said 0274. Let me check on those. Uh, 1206 is not covered. We cover 1208?
[AGENT][NEUTRAL] And that one has an age limit of [PII].
[CUSTOMER][NEUTRAL] Um, would you
[AGENT][NEUTRAL] And let me go ahead and get the.
[AGENT][NEUTRAL] Bear with me.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Well, let me, let me transfer you over to our [PII] office, um, you.
[AGENT][NEUTRAL] OK, so maximum of 1 procedure for 12 months.
[AGENT][NEUTRAL] And it's gonna be admitted to the pending children age [PII] and that's for the 1208 for fluoride.
[AGENT][NEUTRAL] Uh, for the 0074.
[AGENT][NEUTRAL] 274. I'm sorry.
[CUSTOMER][NEUTRAL] 00 0274 sorry.
[AGENT][NEUTRAL] Yes, which is the bitew, um, for the bitew is covered under preventative. The limitation on this one is limited to one bite win X-ray procedures and any combination of 270, 272, or 274 per 12 month period.
[CUSTOMER][NEUTRAL] OK, and then D0330 and 1351 are those covered?
[AGENT][NEUTRAL] I'm sorry, you said 0330?
[CUSTOMER][NEUTRAL] Yes, and 1351.
[AGENT][NEUTRAL] OK, so 0330 is going to be on the radiograph FMX which is 80% limited to one X-ray procedure in any combination of 210, 277, or 330, and that's per 5 year period.
[AGENT][NEUTRAL] OK, and then for the ceilings, uh, there is an age limit of [PII], I'm sorry. That's gonna be uh limited to dependent children age [PII], application made to the molar teeth only a maximum of one procedure for 36 months.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and then 9944, is that covered?
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] No, 9944 is not covered.
[CUSTOMER][NEUTRAL] OK, and then you said 2391, that's covered. What percentage is that at?
[AGENT][NEUTRAL] 2391 that's gonna be under basic which is 80.
[CUSTOMER][NEUTRAL] You said that's at 80?
[AGENT][NEUTRAL] Mhm. Yes.
[CUSTOMER][NEUTRAL] And do you guys downgrade um posterior composites to a Malcolm?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] We don't.
[CUSTOMER][POSITIVE] OK, that's all I need. Thanks so much.
[AGENT][POSITIVE] You're welcome. Is there anything else I may help you with today?
[CUSTOMER][NEUTRAL] Yes, actually, can I just confirm your mailing address, um, it's [PII].
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][POSITIVE] OK, alright, that's all I need. Thank you.
[AGENT][POSITIVE] You're welcome and thank you for calling APO. Have a good day, Ms. [PII].