AccountId: 011433970860
ContactId: 50338ec8-4a4c-4873-8417-f23262d89ebe
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 544479 ms
Total Talk Time (AGENT): 260049 ms
Total Talk Time (CUSTOMER): 158199 ms
Interruptions: 1
Overall Sentiment: AGENT=1.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/02/50338ec8-4a4c-4873-8417-f23262d89ebe_20250102T19:43_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] calling from Day and Night Family Dental. How are you?
[AGENT][POSITIVE] I'm doing well, [PII] how are you?
[CUSTOMER][POSITIVE] I'm good thank you. I needed to check the um.
[CUSTOMER][NEUTRAL] Status on a member's uh benefits if it's a calendar year benefit your plan um and see where that's at first and then I can go from there.
[AGENT][NEUTRAL] Of course.
[AGENT][POSITIVE] Of course, yes, alright, yes, we'll check those benefits. um, what was a good call back number from you first if you don't mind in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK. Thank you. And then do you have the policy number?
[CUSTOMER][NEUTRAL] Yes, 02441184.
[AGENT][NEUTRAL] OK, thank you. One moment.
[AGENT][NEUTRAL] OK, and what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] It is [PII] [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that [PII]. Alrighty, so the policy is active. Effective date was [PII], and this plan does operate on a calendar year.
[CUSTOMER][NEUTRAL] On the calendar year, OK, um, would I be able to get a benefit breakdown over the phone?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, yes, I could send you a fax back as well if you prefer.
[CUSTOMER][NEUTRAL] Um, the patient's here for an ER and they've been waiting for a while. Would I be able to over the phone is preferred, yeah.
[AGENT][NEUTRAL] Oh, I see. Of course.
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][NEUTRAL] Let me get it pulled up here.
[AGENT][NEUTRAL] OK, then of course I will let you know verification of coverage is not a guarantee of payment for claims. Um, what kind of questions did you have for me? where we needed to look up specific codes?
[CUSTOMER][NEUTRAL] Um, yeah, can I have your general breakdown and then I can, um, go from, go from there if I've got anything additional.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, OK, so the calendar year maximum is $1500. There is a deductible. It's uh $50 and that does not apply towards preventative expenses.
[AGENT][NEUTRAL] And so this plan uh operates just off of uh UCR, a percentage off of UCR, uh, so no set network or anything. Uh, preventative is at 100%, radiographs and basic expenses are at 80%. Major and adontic periodontic oral surgery, that's all 40%.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, I'm ready.
[AGENT][NEUTRAL] OK, uh, did you have for, uh, are you gonna give me some codes to look at?
[CUSTOMER][NEUTRAL] Oh well first can I have the group name and group number?
[AGENT][POSITIVE] Oh, sure, let me get that for you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, group number is 16068.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the name is Universal Trucking. I'm not quite sure how this next one is pronounced so I'm just going to spell it. It's uh H I not really H I R S C H B A C H.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] I just want to say
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII]? I'm not sure.
[CUSTOMER][NEUTRAL] And that's OK. When is, uh, the patient's effective date?
[AGENT][NEUTRAL] Uh yes, effective date for this policy was [PII].
[CUSTOMER][NEUTRAL] OK awesome um are there waiting periods are missing tooth clothes?
[AGENT][NEUTRAL] There is a missing teeth clause, uh, waiting periods of 12 months for major endodontic periodontic and oral surgery.
[CUSTOMER][NEUTRAL] What about for basic?
[AGENT][NEUTRAL] Uh, no waiting period for basic or preventative.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So he's almost up for his waiting period. That's good. um, do posterior composites downgrade to amalgam?
[AGENT][NEGATIVE] No, they do not. No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What about crowns on posterior teeth?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Trans and bridges once every 7 years per tooth.
[AGENT][NEUTRAL] Uh let's see.
[AGENT][NEUTRAL] Did you have a specific code?
[CUSTOMER][NEUTRAL] 2740.
[AGENT][NEUTRAL] OK, give me just a moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Yes, that is covered under major, let me look at the limitations.
[AGENT][NEUTRAL] OK, yeah, so just a maximum of 1 per 7 year period and then uh limited to patients over [PII], so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, what about the replacement time for crowns and dentures? I'm, I'm sorry, bridges and dentures, 6750 and 5110.
[AGENT][NEUTRAL] 6750.
[AGENT][NEUTRAL] Uh, what was the other one? I'm sorry.
[CUSTOMER][NEUTRAL] Uh, 5110.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 6750.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] It's also covered under major, so 40% and the same limitations as the other ones for 7 years, and let me look at 5110.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, that one is also covered under major, however, the different limitation.
[AGENT][NEUTRAL] That one is a maximum of 1 per 5 year period.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, let's see, the frequencies I have, um, cleanings are 1 in 6 months.
[CUSTOMER][NEUTRAL] Exams 2 and 12.
[AGENT][NEUTRAL] That's correct, yes, once every 6 months for cleaning exams, 2 for 12 month period.
[CUSTOMER][NEUTRAL] OK, no.
[CUSTOMER][NEUTRAL] Does the 0140 share with the routine exam of 0120?
[AGENT][NEUTRAL] I believe so, let me verify.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, it does.
[CUSTOMER][NEUTRAL] OK, and then I have bite wings 1 and 12 months.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK, and then no frequency for peri apicals?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, and then pano 1 in 5 years or is it 1 in 60 months?
[AGENT][NEUTRAL] 1 every 5 years.
[CUSTOMER][NEUTRAL] OK, does, um, oh, and the last code I need to see if you have is um palliative treatment [PII].
[AGENT][NEUTRAL] Yes, that is covered under, uh, as a basic expense, and there are no limitations.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, now does the patient have any history like of the cleaning, X-ray or exam?
[AGENT][NEUTRAL] Oh, let me check.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright.
[AGENT][NEUTRAL] I do see that they have received a panel um.
[AGENT][NEUTRAL] 0330 that was [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Ticket bye wings uh 0274 that was also on [PII] and then a comprehensive oral evaluation [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And has the patient used anything this year?
[AGENT][NEUTRAL] Um, let me see, I don't believe so, but we'll see.
[AGENT][NEUTRAL] Oh my goodness, I'm still putting in 2024. I was like, yeah, I did.
[AGENT][NEUTRAL] Goodness. OK. Yup, no, nothing so far this year.
[CUSTOMER][NEUTRAL] OK perfect and then does the max go towards all services?
[AGENT][NEUTRAL] Uh, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And can I have the claims mailing address please?
[AGENT][NEUTRAL] Yes, it is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[AGENT][NEUTRAL] I also got a fax number and a payer ID if you'd like for me.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I'll take both.
[AGENT][NEUTRAL] OK, yeah, fax number is [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK, and the payer ID?
[AGENT][NEUTRAL] And the payer ID is, yes, 60801.
[CUSTOMER][POSITIVE] 60801. OK, awesome thank you so much for your help.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] Yes, is there anything else I can help you with?
[CUSTOMER][NEUTRAL] No ma'am, that'll be all.
[AGENT][POSITIVE] Alright, yeah, thanks for calling API. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you bye bye