AccountId: 011433970860
ContactId: 4c632107-26ca-4d22-92f1-9036fe8aa516
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 834039 ms
Total Talk Time (AGENT): 329732 ms
Total Talk Time (CUSTOMER): 219986 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/08/4c632107-26ca-4d22-92f1-9036fe8aa516_20250508T19:32_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from provider's office looking for dental benefits.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] OK, I can verify benefits for you, Ms. [PII], and spell your name for me, please.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] Uh, spell your name for me.
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[AGENT][NEUTRAL] OK, thank you. And Miss [PII], what is the policy number, please?
[CUSTOMER][NEUTRAL] Yes, I do have the ID like.
[CUSTOMER][NEUTRAL] 023
[CUSTOMER][NEUTRAL] 65
[CUSTOMER][NEUTRAL] 849
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Sure. Callback number [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you. And
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Oh, I'm so sorry. I cut you off. I apologize. What was the extension?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Awesome. Thank you, Ms. [PII]. And verify the patient's name, date of birth.
[CUSTOMER][NEUTRAL] Yes. Patient's name, [PII]. Date of birth, uh [PII].
[AGENT][NEUTRAL] Thank you. And you say you're calling to verify benefits and eligibility.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, I've shown his effective date is [PII]. He is active on the policy, and I just need general benefits or I can send you a fax back.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yes, I have some specific questions. Uh, can you fax back as for the benefits?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, what's your fax number?
[CUSTOMER][NEUTRAL] Fax number [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you. I can send you that fax back.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. And
[AGENT][NEUTRAL] You say you had other questions as well?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and what are your questions?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Yes. Can you check the provider is in-network or out of network and the schedule?
[AGENT][NEUTRAL] Uh, we don't have a network and this policy doesn't pay by fee schedule, it pays by UCR.
[CUSTOMER][NEUTRAL] OK. Um,
[CUSTOMER][NEUTRAL] What is the plan type of the patient? Is this PPO plan?
[AGENT][NEUTRAL] It's just a group dental, it pays by usual customary and reasonable, doesn't have a fee schedule.
[CUSTOMER][NEUTRAL] OK. Uh, just to confirm, is this PPO plan or a HMO plan?
[AGENT][NEUTRAL] Neither. It's just a, just a limited group dental plan.
[CUSTOMER][NEUTRAL] OK. Um, can I have the patient's group number and the group name?
[AGENT][NEUTRAL] Sure. The group number is 19867.
[AGENT][NEUTRAL] Group name is Universal Trucking. Purdy Brothers, P U R D Y Brothers Trucking.
[CUSTOMER][NEUTRAL] One moment, one moment.
[CUSTOMER][NEUTRAL] Uh, university.
[AGENT][NEUTRAL] No, Universal Trucking.
[CUSTOMER][NEUTRAL] Any what?
[CUSTOMER][NEUTRAL] Tracking
[AGENT][NEUTRAL] Correct. Purdy Brothers, P U R D Y and then Brothers Trucking.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Is this calendar year plan?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Oral surgery goes to medical first or dental?
[AGENT][NEUTRAL] Just dental.
[CUSTOMER][NEUTRAL] Any waiting period and missing tooth cloth?
[AGENT][NEUTRAL] Uh, there is a 12-month waiting period which he's already satisfied and there is a missing tooth clause.
[CUSTOMER][NEUTRAL] I think the, OK.
[CUSTOMER][NEUTRAL] Can I have the individual deductible and met amount?
[AGENT][NEUTRAL] I'm sorry, say that one more time.
[CUSTOMER][NEUTRAL] Individual deductible and met amount.
[AGENT][NEUTRAL] OK. Uh, the patient has a $50 deductible.
[AGENT][NEUTRAL] That is applied to everything but preventative services.
[AGENT][NEUTRAL] And he has not met his deductible for the year.
[CUSTOMER][NEUTRAL] Mhm. And what is the annual maximum and the used amount?
[AGENT][NEUTRAL] Uh, not a guarantee of payment, just the verification of coverage. The insured has a benefit max of 1500 per calendar year, and they have not met their benefit met, uh, they have not met any of their benefits for the year.
[CUSTOMER][NEUTRAL] Mhm. OK. I have some procedure reports to check the coverage and frequency. Can you help with that?
[AGENT][NEUTRAL] Sure, what are the codes?
[CUSTOMER][NEUTRAL] Uh, can I say all at once or one at a time?
[AGENT][POSITIVE] All at once is fun.
[CUSTOMER][NEUTRAL] Sure. The codes are 0140.
[CUSTOMER][NEUTRAL] 0150
[CUSTOMER][NEUTRAL] 9310.
[CUSTOMER][NEUTRAL] 0330
[CUSTOMER][NEUTRAL] 7111.
[CUSTOMER][NEUTRAL] 7140.
[CUSTOMER][NEUTRAL] 7 to 10.
[CUSTOMER][NEUTRAL] 7220.
[CUSTOMER][NEUTRAL] 70 to 30.
[CUSTOMER][NEUTRAL] 70 to 40.
[CUSTOMER][NEUTRAL] 7241.
[CUSTOMER][NEUTRAL] 7250.
[CUSTOMER][NEUTRAL] 7251.
[CUSTOMER][NEUTRAL] 7310
[CUSTOMER][NEUTRAL] 7311.
[CUSTOMER][NEUTRAL] 9222.
[CUSTOMER][NEUTRAL] And then 7410.
[CUSTOMER][NEUTRAL] 7286.
[CUSTOMER][NEUTRAL] 7472.
[CUSTOMER][NEUTRAL] 6010
[CUSTOMER][NEUTRAL] 6056.
[CUSTOMER][NEUTRAL] 6104.
[CUSTOMER][NEUTRAL] 7956.
[CUSTOMER][NEUTRAL] 7957.
[CUSTOMER][NEUTRAL] 7950.
[CUSTOMER][NEUTRAL] 7951.
[CUSTOMER][NEUTRAL] 7952.
[CUSTOMER][NEUTRAL] 7953.
[CUSTOMER][NEUTRAL] 7921.
[CUSTOMER][NEUTRAL] Um, that's it.
[AGENT][NEUTRAL] OK, hold on one moment please.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, give me one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Well, the 140 150, all exams share the same frequency of 2 for 12 month period. Uh, the 140.
[AGENT][NEUTRAL] is considered basic, so it pays at 80%, the 150 is considered preventative and it pays 100% of UCR.
[AGENT][NEUTRAL] The 9310. 1 moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That falls under
[AGENT][NEGATIVE] Basic, there's no frequency.
[AGENT][NEUTRAL] And you said 330. The panoramic is basic, and it's once every 5 years and it does share frequency with a full mouth X-rays?
[AGENT][NEUTRAL] Uh, 7110. 1 moment.
[CUSTOMER][NEUTRAL] 7111.
[AGENT][NEUTRAL] You said 7111?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Uh, 7111, it falls under basic and it's one time per tooth.
[AGENT][NEUTRAL] 7140 is basic.
[AGENT][NEUTRAL] Of course, that's once for 2 cents and it's extraction. The 7210.
[AGENT][NEUTRAL] 7220, 7230, 7240, 7241, 7250.
[AGENT][NEUTRAL] All those fall on an oral surgery and that is major and major pays at 40% of UCR.
[AGENT][NEUTRAL] 7251, not covered.
[AGENT][NEUTRAL] 7310.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] One per lifetime per quad, and that falls on a major.
[AGENT][NEUTRAL] Say 7311.
[AGENT][NEUTRAL] Not covered?
[AGENT][NEUTRAL] 9222.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, one moment. What about for 7310?
[AGENT][NEUTRAL] 7310.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I said that one is one per lifetime per quadrant, and it falls on a major.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For the 9222, what is that code for?
[CUSTOMER][NEUTRAL] 90 to 22 uh for general anesthesia.
[AGENT][NEUTRAL] Uh, that falls under a major.
[AGENT][NEGATIVE] There's not a uh frequency. The 7410 is major.
[AGENT][NEUTRAL] And it states.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] X-rays and path report is required.
[AGENT][NEUTRAL] 7286.
[AGENT][NEUTRAL] Falls under major and X-rays and path report required.
[AGENT][NEUTRAL] 7472.
[AGENT][NEUTRAL] Uh, that falls on a major, one is per lifetime.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 6010 is not covered. Is that for um
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Implant
[CUSTOMER][NEUTRAL] Implant
[AGENT][NEGATIVE] Not cover.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So the 6050, um 6010, 6056, and 6104 are not covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 7956.
[AGENT][NEGATIVE] Not covered.
[AGENT][NEGATIVE] 7957 not covered, 7950 not covered, 7951 not covered, 7952 or 53 not covered, 7921 not covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you so much. Can you please double check, um,
[CUSTOMER][NEUTRAL] 9612.
[AGENT][NEUTRAL] And what is that code for, because I don't show it as being covered.
[CUSTOMER][NEUTRAL] OK. 9612 for therapeutic parental.
[AGENT][NEGATIVE] Uh, it's not covered.
[CUSTOMER][NEUTRAL] Not covered? OK. Uh, and then what about for general anesthesia?
[AGENT][NEUTRAL] As I told you that was major.
[CUSTOMER][POSITIVE] Major. Thank you so much. OK. Can you check if there any history for exams and then for pan RFMX?
[AGENT][NEUTRAL] No, he doesn't have any history.
[CUSTOMER][NEUTRAL] No history at all. OK. And let me confirm for exam, same-day treatment is allowed or not allowed?
[AGENT][NEGATIVE] Uh it's so loud.
[CUSTOMER][NEUTRAL] Allowed?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] OK. Thank you so much. Can I have the claim mailing address and the payer ID?
[AGENT][NEUTRAL] Pay ID is 60801. The mailing address is [PII].
[AGENT][NEUTRAL] [PII], [PII].
[CUSTOMER][NEUTRAL] Got it. Can I have the call reference number and spelling of your name?
[AGENT][NEUTRAL] Uh, my name is spelled [PII], last initial [PII], and you can use my name in today's date as a reference.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yes, got it. Thank you so much. Thank you for the benefits. Have a wonderful day.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Bye.
[CUSTOMER][NEUTRAL] Bye.