AccountId: 011433970860
ContactId: 5a642bec-73ce-49e5-b5ae-a6c707bbad98
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1088449 ms
Total Talk Time (AGENT): 294523 ms
Total Talk Time (CUSTOMER): 433158 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/31/5a642bec-73ce-49e5-b5ae-a6c707bbad98_20241231T17:39_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] and I'm calling in from Bella Family Dentistry to get the dental benefits of the patient.
[AGENT][POSITIVE] I'm happy to check on benefits for you today. May I have their policy number?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The policy number is 657181669.
[AGENT][NEUTRAL] Let me try and bring this up here. Give me one moment please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Unfortunately, that's not coming up as a valid policy number. Do you have their name or social?
[CUSTOMER][NEUTRAL] Yeah, let me check. Yeah, the social is [PII], actually that's the social number itself I think.
[CUSTOMER][NEUTRAL] Let me give it to you again.
[AGENT][NEUTRAL] Oh, that's the social. Let me try, let me try by that then.
[AGENT][NEUTRAL] And do you have a good call back number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And what's the patient's first and last name?
[CUSTOMER][NEUTRAL] [PII] is the first and last name of the patient.
[CUSTOMER][NEUTRAL] And uh
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] All right, thank you so much. So I was able to locate a patient plan that's active. Would you like the policy number?
[CUSTOMER][NEUTRAL] Uh, that will be just give me a moment, let me first pull up some details.
[CUSTOMER][NEUTRAL] In function that I've given you.
[CUSTOMER][NEUTRAL] However, you can go ahead, uh, provide me the member ID first while I check the details.
[CUSTOMER][POSITIVE] Good.
[AGENT][NEUTRAL] Member ID is 02.
[AGENT][NEUTRAL] 576502.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's it. 02576502.
[AGENT][POSITIVE] Mhm. Correct.
[CUSTOMER][NEUTRAL] OK, just give me a moment, let me just check my resources here, OK?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] in public life.
[CUSTOMER][NEUTRAL] So, uh, just, so this is an active policy, right? You've checked it from my records.
[AGENT][NEUTRAL] Yes. Patient plan is active. The effective date is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh any future termination date?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, let me quickly.
[CUSTOMER][NEUTRAL] this
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Right, so let's continue.
[CUSTOMER][NEUTRAL] Uh, just to confirm, you said this policy is active and uh,
[CUSTOMER][NEUTRAL] Can you provide me the effective date again so we have to update it in my records. I was just checking it earlier.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]. So it got recently.
[CUSTOMER][NEUTRAL] Active, OK. And uh [PII], uh, it's a calendar year or a benefit year policy?
[AGENT][NEUTRAL] Calendar year.
[CUSTOMER][NEUTRAL] OK. And uh no future termination date given and uh spell your name for me?
[AGENT][NEUTRAL] My name is spelled [PII]
[CUSTOMER][NEUTRAL] [PII], OK.
[CUSTOMER][NEUTRAL] And uh also,
[CUSTOMER][NEUTRAL] Uh, I have here the claim filing address for this insurance as [PII].
[CUSTOMER][NEUTRAL] And the [PII], is that correct?
[AGENT][NEUTRAL] No, that is not correct. Let me give you the corrected mailing address.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it's going to be [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's in [PII], [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] OK, after that,
[CUSTOMER][NEUTRAL] [PII], correct?
[AGENT][NEUTRAL] Mhm. Right.
[CUSTOMER][NEUTRAL] Their ID is 60801.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] do
[CUSTOMER][NEUTRAL] 60
[CUSTOMER][NEUTRAL] Also, uh, the group name and number I have in my record, no group name, group number is 70056, is that correct?
[AGENT][POSITIVE] Yes, that is correct uh huh.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] OK, 70056. No group name. It's an individual policy, I think, right?
[AGENT][NEUTRAL] The group name is Man analysis and utilization.
[CUSTOMER][NEUTRAL] Oh, just a second, management analysis.
[AGENT][NEUTRAL] And utilization.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And utilization.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Alright, management analysis and utilization, uh.
[CUSTOMER][NEUTRAL] And on this policy, uh.
[CUSTOMER][NEUTRAL] [PII], right? The name of the patient?
[CUSTOMER][NEUTRAL] Date of birth [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] Also, on this policy, [PII] is a subscriber, correct? an individual policy as I mentioned.
[CUSTOMER][NEUTRAL] And uh alright so let's continue.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] You mentioned that the correct member ID let me update this in my record now.
[CUSTOMER][NEUTRAL] It is
[CUSTOMER][NEUTRAL] 02576502.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. So it is updated now. 02576502, correct?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, and, uh, what, so for out of network provider, uh, what is the deductible and max and how much has the patient used?
[AGENT][NEUTRAL] The calendar year maximum is 500 per insured and the deductible is $50 per insured up to $150 per family.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Used
[AGENT][NEUTRAL] Uh, patients still have a full $500 left and they have not met their deductible.
[CUSTOMER][NEUTRAL] Both individual and family, nothing went out of the deductible.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, no $500 no. What is the coinsurance for preventive basic and major?
[AGENT][NEUTRAL] Preventative is covered at 100%.
[AGENT][NEUTRAL] Basic is covered at 80%.
[AGENT][NEGATIVE] This plan has no major coverage.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Major restorative is not covered. And what about endo Peru and oral services?
[AGENT][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] All three of them.
[CUSTOMER][NEUTRAL] Indo, Peru and O.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, any waiting period or missing tooth cloths?
[AGENT][NEUTRAL] No waiting period. This policy does have a missing tooth clause.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] What about, so I have some codes for which I need the coverage and frequency. Can I provide you all the coded ones?
[AGENT][NEUTRAL] Yup, go ahead.
[CUSTOMER][NEUTRAL] So the codes are 0120014001500180.
[CUSTOMER][NEUTRAL] 1110 02720210.
[CUSTOMER][NEUTRAL] 12081351434149105821.
[CUSTOMER][NEUTRAL] 60109243
[CUSTOMER][NEUTRAL] 9944.
[CUSTOMER][NEUTRAL] 274-079-53
[CUSTOMER][NEUTRAL] And also coverage.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEGATIVE] OK. There is no ortho coverage on this plan.
[CUSTOMER][NEGATIVE] No the coverage at all.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] 0120.
[CUSTOMER][NEUTRAL] No
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][POSITIVE] Good.
[CUSTOMER][NEUTRAL] Go ahead, uh,
[AGENT][NEUTRAL] 0120 is covered under preventative at 100% limited to two oral evaluation procedures and any combination does share the same frequency with 01400150.
[CUSTOMER][NEUTRAL] OK. 24503 share frequency and 0180.
[AGENT][NEUTRAL] Correct. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 0180 is not listed therefore it's not covered.
[AGENT][NEUTRAL] 11:10 is covered under preventative at 100%. It is a maximum of 1 procedure per 6 months.
[CUSTOMER][NEUTRAL] Uh sorry just.
[CUSTOMER][NEUTRAL] Sorry, uh, uh, go ahead with 1110 again please.
[AGENT][NEUTRAL] 1110 is covered at 100% under preventative.
[AGENT][NEUTRAL] Limitation is a maximum of 1 procedure per 6 months.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 1 for 6 months.
[CUSTOMER][NEUTRAL] 4 1110, OK.
[CUSTOMER][NEUTRAL] 100% for 6 months. What about the sex is 0272?
[AGENT][NEUTRAL] I'm looking for one moment, please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 0272 is covered under preventative as well at 100%. It does carry a limitation, limited to one bite X-ray uh procedure for 12 months.
[CUSTOMER][NEUTRAL] 1 for 12 months 100% next.
[AGENT][NEUTRAL] 0210 is covered at 80%, limited to one X-ray procedure for five years, shares the same frequency with 01 or 0210.
[CUSTOMER][NEUTRAL] Uh, OK, chest frequency FMX and panel uh covered at 100%. Frequency again, please?
[AGENT][NEUTRAL] Uh, no, that's covered at 80%.
[CUSTOMER][NEUTRAL] OK, frequency.
[AGENT][NEUTRAL] Frequency again is limited to 1 X-ray procedure for 5 years.
[CUSTOMER][NEUTRAL] 5 calendar years. OK, 80% basic and the share frequencyFM expand.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 1208 is not listed, therefore, it's not covered.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK, sealants.
[AGENT][NEUTRAL] 1351 is covered under preventative at 100%. It's a maximum of one procedure per 36 months limited to dependent children under the age of 14. Applic applications made to permanent molar teeth only.
[CUSTOMER][NEUTRAL] Permanent molar teeth only. And uh also to confirm, just a second. Permanent molar teeth, 1 for 36 months. I is it uh preventive or basic?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Preventative.
[CUSTOMER][NEUTRAL] OK. 136 months, 100%, under 14 permanent molar teeth.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. 4341.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] 4341 is not listed, therefore not covered.
[CUSTOMER][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] OK. 4341, right?
[AGENT][NEUTRAL] 4910.
[AGENT][NEUTRAL] Yes, correct. 4
[CUSTOMER][NEUTRAL] 4341 is not. OK. OK.
[AGENT][NEUTRAL] Correct, not listed.
[AGENT][NEUTRAL] 4910 is not listed, therefore not covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 5821.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Not listed, therefore not covered.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 6010.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Not listed, therefore not covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Bridge crowns, crowns, bridges, and dentures, are they covered?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEGATIVE] Not covered bridges, benches, and crowns also.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] 7:40. OK. What about the implants? They are also not covered, right?
[AGENT][MIXED] Correct, not covered.
[CUSTOMER][NEUTRAL] 6010 you already mentioned 9243.
[AGENT][NEGATIVE] 9243 is not listed, therefore not covered.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 9944 not listed.
[CUSTOMER][NEUTRAL] 9944.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 2740.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEGATIVE] Mhm, not covered.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] You mentioned cos.
[CUSTOMER][NEUTRAL] 7953.
[AGENT][NEGATIVE] Not listed, therefore not covered.
[CUSTOMER][NEGATIVE] 7 not good. OK. And what about the, do you downgrade the posterior composite to amalgam?
[AGENT][POSITIVE] There's no downgrade.
[CUSTOMER][NEUTRAL] No downgrade for that.
[CUSTOMER][NEUTRAL] And it is covered at 80% basic, right? The fillings, the, yes, filling.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. You mentioned 80 person fillings. OK. And uh what the author is also not covered, you already mentioned.
[CUSTOMER][NEGATIVE] Not good.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Any history on file for preventive and diagnostic services?
[AGENT][NEGATIVE] No history on file.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No history on file, patient is eligible, right?
[CUSTOMER][NEUTRAL] For FMX and panel for all the services, basically.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So no patient is eligible and as for the age of this patient, uh [PII] old.
[CUSTOMER][NEUTRAL] Pa will not be eligible for students under [PII].
[CUSTOMER][NEGATIVE] is not eligible.
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. Can you provide me a reference number now for this call?
[AGENT][NEUTRAL] Call references my name with my last initials and today's date. My name again is [PII], that is spelled [PII] The last initial to my name is [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And today's date? [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK, [PII]. So that would be it. Thanks for providing all the details. Have a nice day.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] You're welcome. You too, bye bye.
[CUSTOMER][NEUTRAL] Bye bye.