AccountId: 011433970860
ContactId: 48089a33-0f4b-43af-9bd4-bf6016e71c46
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1109859 ms
Total Talk Time (AGENT): 298180 ms
Total Talk Time (CUSTOMER): 531142 ms
Interruptions: 9
Overall Sentiment: AGENT=0.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/06/48089a33-0f4b-43af-9bd4-bf6016e71c46_20250606T19:44_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] All right. My name is [PII] from provider's office. How are you doing today? How do you spell your name, you say?
[AGENT][NEUTRAL] [PII] last initial [PII]
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So with the American Public Life APL, there is a medical only or medical and dental both kind of policy you're handling?
[AGENT][NEUTRAL] Uh, it depends on the type of policy the insured has cause we do have dental policies and we have medical policies.
[AGENT][NEUTRAL] Uh, OK.
[CUSTOMER][NEUTRAL] So, one sec. Actually, I have medical dental both for this member. So that's the the reason I'm just confirming that.
[AGENT][NEUTRAL] OK, and you say your name is [PII]?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, and you're calling for benefits?
[CUSTOMER][POSITIVE] You are right.
[AGENT][NEUTRAL] OK, and what is the policy number?
[CUSTOMER][NEUTRAL] OK. Let me give you the medical policy number first, OK?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] All right. Medical policy number which I have would be
[CUSTOMER][NEUTRAL] 026 [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Give me one moment. Do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Definitely, sure. Mhm. It's [PII].
[AGENT][POSITIVE] OK thank you give me one moment.
[CUSTOMER][NEUTRAL] You're welcome. Mhm.
[AGENT][NEUTRAL] OK, and the patient's name, date of birth?
[CUSTOMER][NEUTRAL] Patient name would be [PII].
[CUSTOMER][NEUTRAL] OK, one second. And yup. And date of birth would be [PII].
[AGENT][NEUTRAL] OK. And what benefits are you needing for this patient?
[CUSTOMER][NEUTRAL] I do have a specific question if you don't mind kicking.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, can we go ahead with the effective date first for this patient?
[AGENT][NEUTRAL] Uh, effective date, [PII].
[CUSTOMER][NEUTRAL] [PII]. OK.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Is it best to calendar your contract here?
[AGENT][NEUTRAL] Calendar year.
[CUSTOMER][NEUTRAL] All right. And uh which type of plan is this?
[AGENT][NEUTRAL] It's a limited medical indemnity plan.
[CUSTOMER][NEUTRAL] 1 2nd.
[CUSTOMER][NEUTRAL] Limited
[CUSTOMER][NEUTRAL] Medical indemnity plan.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. And with this type of policy, is there any network will apply or there will be no network?
[AGENT][NEUTRAL] Uh, we don't have a network.
[CUSTOMER][NEUTRAL] OK. And is there any group number maybe applicable on this type of plan for billing purpose?
[AGENT][NEUTRAL] Uh, group number 70056.
[CUSTOMER][POSITIVE] 70056. Thank you so much. And how about the mailing address to submit the claim?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] One second. I'm looking on the ZIP code [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] OK, perfect. Thank you so much.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And this is for medical mailing address you are sharing with me, right?
[AGENT][NEUTRAL] That's for any claims for our company.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Medical and dental both same, right? Common claim mailing address? All right. Perfect. Thank you. And phone number also the same for APL like [PII] for medical and dental both?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] All right. Thank you. And
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] For this patient, I do wanna confirm for
[CUSTOMER][POSITIVE] There is no network usage, perfect. And yeah, I do have CPT code 96374. Service will be in office setting.
[CUSTOMER][NEUTRAL] It will be done by
[CUSTOMER][NEUTRAL] Oral surgeon
[CUSTOMER][NEUTRAL] And looking for professional charges like billing as a professional, OK?
[AGENT][NEUTRAL] And what was that procedure code?
[CUSTOMER][NEUTRAL] Yeah, it's 963-74.
[AGENT][NEUTRAL] OK, and you're wanting to know what again?
[CUSTOMER][NEUTRAL] Benefit.
[AGENT][NEUTRAL] Give me one moment.
[CUSTOMER][NEUTRAL] I have informed you, I have, sorry, I have given the information that there will be the service will be rendered. If you will ask me in the future, so I have already given you in advance that patient service will be branded at provider's office in office setting, and it will be done. Who gonna perform the service. So it's gonna perform by oral surgeon, performed by professional provider, OK? So I have shared that kind of information with you. OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] See.
[AGENT][NEUTRAL] Um, not a guarantee of payment.
[CUSTOMER][NEUTRAL] And I'm looking for professional charges.
[AGENT][NEUTRAL] Not a guarantee of payment, just a verification of coverage for services performed in office. The max benefit payable is $75 per day, and they have a total of $5 per year.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] Sorry, I'm not getting that. You said for this patient,
[AGENT][POSITIVE] Correct, for procedures in office.
[CUSTOMER][NEUTRAL] Coverage for 963-74.
[AGENT][NEUTRAL] Not just for 96374 for any procedures in office, if it's for sickness, the max we pay is $75 per day, up to $5 per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For any
[CUSTOMER][NEUTRAL] Procedure in office.
[AGENT][NEUTRAL] If it's for a sickness.
[CUSTOMER][NEUTRAL] And if
[CUSTOMER][NEUTRAL] If it is for sickness.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The max we pay is $75 per day.
[AGENT][NEUTRAL] And again, this is not a guarantee of payment, just a verification of coverage.
[CUSTOMER][NEUTRAL] One second. Maximum.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Maximum, OK. So, I have mentioned that for any procedure in office, and if it is for sickness,
[CUSTOMER][NEUTRAL] So it is not kind of sickness like uh we can say mm, just a moment.
[CUSTOMER][NEUTRAL] So there is no, uh, you, you, are you able to identify the codes or something as for the code which I have given? Any specific conclusion you got that, that particular service falls under this kind of category or not like that?
[AGENT][NEUTRAL] Well, you gave the code, and that's typically for sickness. Do you have a diagnosis code?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, yeah, I, I don't have a diagnosis code, so I got it. Thank you. And so for any procedure in the office and if it is for sickness, then maximum that the insurance will pay is $75.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what is that you said per date of service you said?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Per day, up to 5 per year.
[CUSTOMER][NEUTRAL] Per day.
[CUSTOMER][NEUTRAL] And it is up to 5 times per year, right?
[AGENT][NEUTRAL] Up to 5 visits per year.
[CUSTOMER][NEUTRAL] 5 visits per year. OK, 1 2nd.
[AGENT][NEUTRAL] 3415.
[CUSTOMER][NEUTRAL] 5 visits per year. OK. Anything else for this one?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Oh, that's it.
[AGENT][NEUTRAL] That's it.
[CUSTOMER][NEUTRAL] There is no any other information like 100% or 9 to 10 no no figure or anything, any other figure, right?
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK. And uh do you have any update how many visits already done, as you said up to 5 visits per year. So in this year, it's a calendar year, right? So how many visits was already done? OK.
[AGENT][NEUTRAL] Wait one moment.
[AGENT][NEUTRAL] OK, hold on one moment, please.
[AGENT][NEUTRAL] Don't show she's used any, so they are available.
[CUSTOMER][NEUTRAL] OK. Patient did not use any, right?
[CUSTOMER][NEUTRAL] Any
[CUSTOMER][NEUTRAL] Visits
[CUSTOMER][NEUTRAL] Out of 5 visits, right.
[CUSTOMER][NEUTRAL] All right. Is there any timely filing limit to submit the claim for this one?
[AGENT][NEUTRAL] No, we don't have timely filing for any of our policies.
[CUSTOMER][NEUTRAL] OK. And in this type of policy, is there any like maximum or deductible, like this kind of information going to be applicable in this plan, as for the plan design?
[AGENT][NEUTRAL] There's no deductible, co-pay, or co-insurance under the plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] And no PCP referral and no pre-existing clause or waiting period for this patient's plan, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And are you primary or secondary insurance for the member?
[AGENT][NEUTRAL] It doesn't matter either one.
[AGENT][NEUTRAL] They have other insurance, we can be primary or we can be secondary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And how about the removal of impacted tooth? Is it covered under this policy, medical or it is a non-covered service with anything?
[AGENT][NEUTRAL] This policy
[AGENT][NEUTRAL] This policy doesn't cover any dental services, it's medical only.
[CUSTOMER][NEUTRAL] So I do have the diagnosis code. Are you able to just, just have a look once, just try to check, check once if you don't mind.
[AGENT][NEUTRAL] What is the diagnosis code?
[CUSTOMER][NEUTRAL] K as in Kilo,
[CUSTOMER][NEUTRAL] 01.1.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For the impact to the service which I have, uh, additional service other than this first call which I have given, OK?
[AGENT][NEUTRAL] That's not covered. That is dental, which is not covered under this medical policy.
[CUSTOMER][POSITIVE] All right. Thank you so much. And you already provided me the reference number, uh sorry, provided the claim mailing address [PII]. All right.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Patient is the policyholder itself, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII], [PII]. All right.
[CUSTOMER][NEUTRAL] 731-248-950 which you have. All right, perfect. And help me with the reference number KK and I will go with the dental policy number ID, right, after this?
[AGENT][NEUTRAL] You may use my name in today's date as reference, and what is the policy number for dental?
[CUSTOMER][POSITIVE] Perfect. Let me, let me close this if you don't mind, and real quick, OK? Sure. One sec.
[AGENT][NEUTRAL] Mhm. Sure.
[CUSTOMER][NEUTRAL] So [PII], I have, all right. It's 026.
[CUSTOMER][NEUTRAL] 09279.
[AGENT][NEUTRAL] OK. Uh, same effective date of [PII]. Policy is active.
[CUSTOMER][NEUTRAL] OK. So is this a policy that through calendar year, contract year?
[AGENT][NEUTRAL] Calendar year.
[CUSTOMER][NEUTRAL] All right. Group number for billing purpose?
[AGENT][NEUTRAL] The same
[CUSTOMER][NEUTRAL] I have 70056, right?
[AGENT][NEUTRAL] Yes, so it's the same.
[CUSTOMER][NEUTRAL] Yeah, actually, I have closed the previous file. Sorry for that, for medical file. All right, that's fine.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I have mentioned already here like is it a plan type of we can say like is it PPO HM or something and the dental?
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] Is it the same, we can consider?
[CUSTOMER][NEUTRAL] Like limited
[AGENT][NEUTRAL] It's just a group dental policy. No, it's just a group dental policy.
[CUSTOMER][NEUTRAL] Is it an indemnity plan as well under this one?
[CUSTOMER][NEUTRAL] Group dental policy.
[CUSTOMER][NEUTRAL] Any other word other than group dental, no, right? Only group dental policy.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One sec. And
[CUSTOMER][NEUTRAL] OK, and one moment. Yeah, I, what is, is there any like, uh, so in group dental policy, is there any maximum and deductible apply?
[AGENT][NEUTRAL] The insurer has a benefit or not a guarantee of payment, just verification of coverage. The patient has a benefit max up to $500 per calendar year, and they have a $50 deductible that applies to everything but preventative services.
[CUSTOMER][NEUTRAL] In this policy, there is only preventative services are covered, you mean to say, or for only deductible purpose you provided that information?
[AGENT][NEUTRAL] The deductible is applied to everything but preventative. So deductible applies to basic services except for not preventative.
[CUSTOMER][NEUTRAL] OK. OK. Got it.
[CUSTOMER][NEUTRAL] I understand. It's only apply for basic and major. All right. And how about the maximum and used and deductible used amount?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Well, major services is.
[AGENT][NEUTRAL] They have not used any benefits or me their deductible, and under this policy, it does not cover any major services and that would include endo perio and oral surgery.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, so,
[CUSTOMER][NEGATIVE] One second. The first thing you said that uh nothing used towards $500 calendar your max. Let's update this part and deductible also not used.
[CUSTOMER][NEUTRAL] And now you're saying uh for major when we confirm that, so.
[CUSTOMER][NEUTRAL] Under this policy, right?
[CUSTOMER][NEUTRAL] Major services are not covered.
[CUSTOMER][NEUTRAL] Major services are not covered under this policy like um what did you say Eo don't takes, perioddontics?
[AGENT][NEUTRAL] Yes, per I said previously, it's not covered. Endoperio oral surgery, any major service is not covered.
[CUSTOMER][NEUTRAL] And I don't take
[CUSTOMER][NEUTRAL] So endoperio and oral surgery also included, right?
[AGENT][NEUTRAL] Those are considered major, yes.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] And implant and all of those services are.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Those are considered major, so it is not covered under the policy.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] And claim mailing address would be the same?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. Is there any missing tooth loss and waiting period for this patient's policy?
[AGENT][NEUTRAL] There's no waiting period and then there is some missing tooth cloths.
[CUSTOMER][NEUTRAL] And is there any timely filing limit for this one?
[AGENT][NEGATIVE] There are no timely filings for any of our policies.
[CUSTOMER][NEUTRAL] No filing limit for any of this, OK.
[CUSTOMER][NEUTRAL] And predetermination is this required or recommended.
[AGENT][NEUTRAL] It's not required.
[CUSTOMER][NEUTRAL] All right. For oral surgery, it's a non-covered, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] It is, it is due to the waiting, oh no, there is no waiting period, but the service is not covered as for the plan design you mean to say, right? OK.
[AGENT][NEUTRAL] Per the patient's policy is not covered.
[CUSTOMER][NEUTRAL] All right. And are you primary or secondary insurance for this one?
[AGENT][NEUTRAL] Uh, where is it?
[AGENT][NEUTRAL] Either one.
[CUSTOMER][NEUTRAL] So not sure. OK, no information. OK, perfect.
[CUSTOMER][NEUTRAL] And for this policy, I do want to check the codes which I have D as in delta, 70 to 30, 70 to 40. So you said oral surgery is not covered, so those are non-covered under the plan, right?
[AGENT][NEUTRAL] Those are oral surgery, which are considered major, which is not covered under the policy.
[CUSTOMER][NEUTRAL] All right. And anesthesia 9222 and 902 23 also not covered, right?
[AGENT][NEGATIVE] Not covered.
[AGENT][NEUTRAL] Those are considered major not covered.
[CUSTOMER][NEUTRAL] D. 9610 also not covered, right?
[AGENT][NEUTRAL] If it's major is not covered.
[CUSTOMER][NEUTRAL] 9610 therapeutic parental drug.
[CUSTOMER][NEUTRAL] I'm not sure it's a major or not. Could you please check with this patient's policy? Is it considered as a major in the fall and the major category or not for anesthesia, therapeutic drug in?
[AGENT][NEUTRAL] What is the code? Oh, no, anesthesia is not covered. It's considered major.
[CUSTOMER][NEUTRAL] All right. 9610 D. 9610.
[AGENT][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] All right. 70 to 30, 40 also non-covered. Perfect. Thank you. Let me check any of them.
[CUSTOMER][POSITIVE] 30 49 600. Perfect. Nothing else and maximum, one moment.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, perfect. Thank you, sir. And could you please, under this dental policy, is there any network will apply or no network under this dental as well?
[AGENT][NEGATIVE] There is no network.
[CUSTOMER][NEUTRAL] In medical or dental, both of 10 kind of policy, there is no network, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] OK, perfect. Thank you so much. Help me with the reference number for this one.
[AGENT][NEUTRAL] As I stated, you can use on today's date, yes.
[CUSTOMER][NEUTRAL] Same name in today's date, right, you said?
[AGENT][NEUTRAL] She
[CUSTOMER][POSITIVE] OK, perfect. Thank you and have a nice day. Bye for now.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Bye.