AccountId: 011433970860
ContactId: 526beb12-f355-489e-8e35-82112b107ff8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 448910 ms
Total Talk Time (AGENT): 225490 ms
Total Talk Time (CUSTOMER): 141645 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/16/526beb12-f355-489e-8e35-82112b107ff8_20250116T18:59_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. I'm calling because from a dental office. This is our first time we would be working with you, so I have lots of questions. Do you have time?
[AGENT][NEUTRAL] Um, yes, are you a provider or you're calling from the group?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Yes, we are a solo provider of a dental office.
[AGENT][NEUTRAL] OK, and you want to go over dental benefits?
[CUSTOMER][NEUTRAL] First of all, we've never done claims with you, um, and we accept TPO insurances. Can we just submit claims to you via fax or do we need to send in W9 form to qualify for something?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, wait a minute. So you're saying you've never filed a claim with APL before?
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, um, so, first thing, may I have your name?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][NEUTRAL] And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you for that. Hold on one moment.
[AGENT][NEUTRAL] And then let me.
[AGENT][NEUTRAL] Hold on one moment, I'm just going to the provider information.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so yes, you would need to um fill out the W-9, but when you file your first claim with us, that's when we'll put you into our system.
[CUSTOMER][NEUTRAL] Sure. All right. So then, uh, let me, I have a patient who wants to come in and get dental care for, uh, with us. Let me give his information so we can pull up and look into uh some benefit information.
[AGENT][NEUTRAL] OK. And what's the member's policy number?
[CUSTOMER][NEUTRAL] 02580862.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] It's here [PII], and it's [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And so I am showing that the policy is active. It's been effective since [PII].
[AGENT][NEUTRAL] Let me see what type of um policy they have. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so I have the dental policy here and um I can fax you over a copy of the fax back if you need it as well. Um, but did you have particular questions about the benefits?
[CUSTOMER][NEUTRAL] Yes. So I wanted to know what's his maximum of the year?
[AGENT][NEUTRAL] The calendar year max for this policy is $1500.
[CUSTOMER][NEUTRAL] And the deductible?
[AGENT][NEUTRAL] Hold on one moment. How does this go to you? Hold on one second.
[AGENT][NEUTRAL] I'm glad I noticed that. My apologies, that's the wrong policy. So the calendar year max for this policy is $500.
[CUSTOMER][NEUTRAL] Uh, I'm sorry, uh, 500 for deductible?
[AGENT][NEUTRAL] The calendar year max, um, the $1500 that I gave it switched to a different policy type, so I, I gave the wrong amount, the correct amount for the calendar year max is $500.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Ah
[CUSTOMER][NEUTRAL] Oh, only 500. And what is the deductible?
[AGENT][NEUTRAL] It's $50 per person up to $150 per family, but this is an individual policy.
[CUSTOMER][NEUTRAL] And does it apply to uh preventative or just basic and major?
[AGENT][NEUTRAL] Um, basic and major, but this policy does not cover major services.
[CUSTOMER][NEUTRAL] Oh, OK, interesting. OK. Um, just a second. So he doesn't even have much to use then, um.
[CUSTOMER][NEUTRAL] Let's see. Uh, are there annual exams like routine exams, 0 150 or 0 120 covered at 100%?
[AGENT][NEUTRAL] Uh, let me see. Yes, those are preventative, so yes, it's covered um at 100%.
[CUSTOMER][NEUTRAL] And the basic is covered, that's how much?
[AGENT][NEUTRAL] Basic, basic restorative, radiograph and FMX expenses are all covered at 80%.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, there's no major
[CUSTOMER][NEUTRAL] Oh sorry geographic.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The major for our policies include endodontic, periodontic, prosodontic, and oral surgery, um, so all those clothes would not be covered.
[CUSTOMER][NEUTRAL] And how about fillings? Those are basic?
[AGENT][NEUTRAL] I'm feeling basic restorative.
[CUSTOMER][NEUTRAL] Uh, it's OK. So 80%. I have a question. Do you guys, uh, pay to us directly or you send the payment to the patient because they're out of network?
[AGENT][NEUTRAL] Um, it will be sent to you, um.
[AGENT][NEUTRAL] There, as far as the network, whether you are a Carrington provider or not, the benefits are the same. So we'll process the claim as it comes in, um, but the payment can go to you or the patient, depends on what we see on the paperwork.
[CUSTOMER][NEUTRAL] OK, and then do you honor our UCR fee or you have a certain fees we should be following?
[AGENT][NEUTRAL] Um, this is just a standard fee schedule, so it'll
[AGENT][NEUTRAL] Like it's not on UCR, this policy is not. So this would just be with the percentages of allowable.
[CUSTOMER][NEUTRAL] Oh, OK. If I give you numbers, would you say if you're above or below?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] If we give you our UCR fees, would you say if it's above or below of your accepted fee?
[AGENT][NEUTRAL] Well, that's what I'm saying. This policy isn't on UCR, so whatever is submitted for, we would pay 100% of it if it's if it's um preventative 80% if it's allowable. This is not a UCR policy.
[CUSTOMER][NEUTRAL] Ah.
[CUSTOMER][POSITIVE] I see, I see. Thank you so [PII]ch for all your help. That's all I needed to know.
[AGENT][NEUTRAL] All right. Well, was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Oh, just one more thing. Uh, is there fluoride coverage on the patient's account 1206?
[AGENT][NEUTRAL] Um, code 1206 is not a covered code, but there are fluoride codes on this, um, fax back. Did you need a copy of the fax back faxed to you?
[CUSTOMER][POSITIVE] Yes, please. Thank you so much. I can provide our fax number.
[AGENT][NEUTRAL] Sure, what's a good fax number for you?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, should I put attention [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, and that was [PII]?
[CUSTOMER][POSITIVE] That's perfect. You got it.
[AGENT][NEUTRAL] All right, well, I will go ahead and send this over to you right now. Was there anything else I can help you with today, [PII]?
[CUSTOMER][POSITIVE] No, that's all. Thank you so much.
[AGENT][POSITIVE] You're welcome and thanks for calling APL and again all the information provided was a verification of benefits, not a guarantee of payment, and I hope you have a great day.
[CUSTOMER][POSITIVE] You too thank you bye bye.
[AGENT][POSITIVE] Thank you, you're welcome. Bye bye.