AccountId: 011433970860
ContactId: 514b5b59-0b34-4bdc-b71f-f2b7be9ccc0f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 752440 ms
Total Talk Time (AGENT): 193985 ms
Total Talk Time (CUSTOMER): 221884 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.2, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/15/514b5b59-0b34-4bdc-b71f-f2b7be9ccc0f_20250415T17:03_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi there. I, I'm just doing an insurance breakdown and I have some questions on a patient.
[AGENT][NEUTRAL] OK. Can I get your name and a good callback number?
[CUSTOMER][NEUTRAL] The [PII] [PII].
[AGENT][NEUTRAL] OK, [PII], and do you have the policy number of the patient?
[CUSTOMER][NEUTRAL] Uh, yeah, 02584689.
[AGENT][NEUTRAL] And patient name and date of birth?
[CUSTOMER][NEUTRAL] [PII], and date of birth is [PII].
[AGENT][NEUTRAL] OK, and how can I help you?
[CUSTOMER][NEUTRAL] Um, to start out, is there a group name for this policy?
[AGENT][NEUTRAL] Uh, group names, yeah.
[AGENT][NEUTRAL] Uh, looks like it's Oxford Global Resources.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and is there a claims address?
[AGENT][NEUTRAL] Claims address is [PII].
[AGENT][NEUTRAL] [PII], [PII].
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, and then payer ID?
[AGENT][NEUTRAL] Our payer ID is 60801.
[CUSTOMER][NEUTRAL] 1, perfect. And what type of plan year is this?
[AGENT][NEUTRAL] A calendar year.
[CUSTOMER][NEUTRAL] OK, and then what's the timely filing period?
[AGENT][NEGATIVE] Uh, there's no timely filing.
[CUSTOMER][NEUTRAL] And then the fee schedule?
[AGENT][NEUTRAL] Um, this doesn't follow a specific fee schedule. It's just based on what's reasonable and customary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, is there any out of network coverage?
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] So, um, we don't require them to use the network but they can use Carrington.
[AGENT][NEUTRAL] Um, obviously they'll get a discount if they go through that network.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, coordination of benefits.
[AGENT][NEUTRAL] Yes, it's standard.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Are there any waiting periods?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Uh, no, no waiting period.
[CUSTOMER][NEGATIVE] And then missing tooth cross.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And does that OK um dependent age and student age limit?
[AGENT][NEUTRAL] Dependent age is [PII].
[AGENT][NEUTRAL] Um, let's see, it, it depends on the benefit for what we're talking about for.
[AGENT][NEUTRAL] Age limits. So, you want to check on a specific benefit or?
[CUSTOMER][NEUTRAL] Um, yeah, we have that downward with our frequencies of certain codes, but at the top in our policy information ask what the dependent age limit and student age limit is.
[AGENT][NEUTRAL] So again it just depends on the services that are rendered, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So like if it's, for example, um I can send you a fax back too that has all this information.
[CUSTOMER][NEUTRAL] OK, um, sure, um.
[AGENT][NEUTRAL] Do you want to check on some other information?
[CUSTOMER][POSITIVE] Yeah, we can do that.
[AGENT][NEUTRAL] OK, or do you wanna just let me.
[CUSTOMER][NEUTRAL] Yeah, um, if we can.
[CUSTOMER][NEUTRAL] Well, I, you read off the facts back? Is that where you get all your information from?
[AGENT][NEUTRAL] I have a policy certificate that's like a 33 page document, but the fax back has the schedule of benefits and then it has all of the codes that are covered under the policy and then which level it's covered under.
[CUSTOMER][NEUTRAL] OK, um, yeah, if I could just ask you because I'll have like history questions and everything too.
[AGENT][NEUTRAL] It's
[AGENT][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] Um, just to continue where we're at, the, um, what is the annual maximum and then individual deductible and family deductible?
[AGENT][NEUTRAL] Um, and by the way, this is not a guarantee of payment, basic outline of the policy. Uh, the calendar benefit maximum is 500.
[AGENT][NEUTRAL] Um, preventative services pay 100%. Basic is 80%.
[AGENT][NEUTRAL] Basic does include radiographs, so that's gonna include FMX, um, the $50 deductible and then pays 80%.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then um individual deductible and family deductible.
[AGENT][NEUTRAL] Individuals 50 families 150.
[CUSTOMER][NEUTRAL] 150 and then what's the percent covered for major services?
[AGENT][NEGATIVE] There's no coverage for major.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and then for code D4346, is that 80% as well or is that different?
[AGENT][NEUTRAL] 4346.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, I don't show that covered.
[CUSTOMER][POSITIVE] OK. Perfect.
[CUSTOMER][NEUTRAL] Um, and then how about frequency for exams 0120 and 0150?
[AGENT][NEUTRAL] And that is
[AGENT][NEUTRAL] Uh, 2 procedures in any 12-month period.
[CUSTOMER][NEUTRAL] OK, and does that share frequency with all others with 0140?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] Um, how about for profies, uh, 1110 and 1120?
[CUSTOMER][NEUTRAL] You know frequency and child pro age limit?
[AGENT][NEUTRAL] That is, let me see here.
[AGENT][NEUTRAL] Limited to dependent children under age [PII], maximum of 1 procedure for 6 months.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, how about fluoride 1206?
[AGENT][NEUTRAL] And that is, let's see.
[AGENT][NEUTRAL] A max of 1 procedure for 12 months, limited to dependent children under age [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, how about silver damine 1354?
[AGENT][NEUTRAL] I don't have that code listed.
[CUSTOMER][NEUTRAL] OK, so not covered?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, um, how about by wings 0272 0274?
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Uh, limited to one bite wing every 12 month period.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, pano FMX 0210 and 0330.
[AGENT][NEUTRAL] Uh, that's limited to one per 5-year period.
[CUSTOMER][NEUTRAL] And is there an age limit?
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And how do you pay if by means of panel are taken on the same data services pay as bill or convert to FMX?
[AGENT][NEUTRAL] Uh, pay his bills.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and then is there a frequency for PA 02200230?
[AGENT][NEUTRAL] Um, no.
[CUSTOMER][NEUTRAL] OK. How about for Seances 1351?
[AGENT][NEUTRAL] A max of 1 for 36 months.
[AGENT][NEUTRAL] For molar teeth only, children under age [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And sorry, what teeth did you say for that?
[AGENT][NEUTRAL] Molars only.
[CUSTOMER][POSITIVE] Oh OK perfect.
[CUSTOMER][NEUTRAL] Um, how about space maintainer 1510.
[AGENT][NEUTRAL] And that is for children under age [PII] and
[AGENT][NEUTRAL] That's one per lifetime per quadrant or arch.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And does the missing tooth cross apply to that?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, um, how about stainless steel crowns, 2930 and 2934.
[AGENT][NEGATIVE] There's no major coverage.
[CUSTOMER][NEUTRAL] Oh, right.
[CUSTOMER][NEUTRAL] Sorry, um, for 2391 to 23 or 2 2394, and you know if it downgrades to amalgam.
[AGENT][NEGATIVE] No, it doesn't.
[CUSTOMER][NEUTRAL] And then are there any fillings, frequency limits?
[AGENT][NEUTRAL] No, there's not.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Um, is there any frequency for 7961 and 7962?
[AGENT][NEUTRAL] Um, I don't see those codes listed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, can I check history on this patient and the sibling?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, just any history for the last two visits on, um, continuing care, and then also any history for crowns, panels, sealants, or fillings?
[AGENT][NEUTRAL] Um, I don't have any history for [PII].
[CUSTOMER][NEUTRAL] And then [PII]
[AGENT][NEUTRAL] Uh, I don't have any history for him either.
[CUSTOMER][POSITIVE] OK, perfect. Thank you so much. Um, I will just need your name again and then a call reference number, please.
[AGENT][NEUTRAL] Uh, reference number is just my name, [PII], first initial to last name, [PII], and today's date.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect thank you so much, [PII].
[AGENT][POSITIVE] OK, thanks for calling APL. Have a great day.
[CUSTOMER][POSITIVE] Thank you you too.