AccountId: 011433970860
ContactId: 5c503bcf-bf83-4c62-bf85-956d7c0103e1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 581359 ms
Total Talk Time (AGENT): 246624 ms
Total Talk Time (CUSTOMER): 203535 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.1, CUSTOMER=2.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/5c503bcf-bf83-4c62-bf85-956d7c0103e1_20250213T21:00_UTC.wav
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[AGENT][POSITIVE] Thanks for calling. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Uh, hi, my name is [PII]. I'm calling you today on behalf of the dental office to check the eligibility and benefits for a specific patient on a recorded line. Could you please help me with that?
[AGENT][NEUTRAL] Sure. Can I have a callback number for you just and the policy number of the member.
[CUSTOMER][NEUTRAL] Sure. The callback number is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the policy number I do have, it is 231-0977.
[AGENT][NEUTRAL] Could you verify the patient's name and date of birth that you're inquiring eligibility and benefits for.
[CUSTOMER][NEUTRAL] Sure. It is uh [PII]. So, it's [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you, [PII] you're calling to verify benefits eligibility. This member's policy has been active since [PII] and is currently active.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Thank you. And uh what about the provider? Can you help me with the information about the provider as well?
[AGENT][NEUTRAL] Well, I can't verify if a provider is in network or not. However, I can transfer you to [PII] to verify if you're in network. Would you like for me to transfer you to?
[CUSTOMER][POSITIVE] OK, that's absolutely
[CUSTOMER][NEUTRAL] Uh, no, that's absolutely fine because uh I need the eligibility and benefits. So as you told me, the effective date is [PII]. Is this a single policy or a family policy plan?
[AGENT][NEUTRAL] Single with a maximum benefit amount of $500 per calendar year with a $50 deductible that does not apply to preventative services, and this is not a guaranteed benefits, just a disclaimer of the policy's coverage.
[CUSTOMER][NEUTRAL] OK, hold on. Just bear with me. I'm just taking a note of it.
[CUSTOMER][NEUTRAL] So, now, this is a single policy. What about the group name and the number, please?
[AGENT][NEUTRAL] The group name is Creative Circle LLC.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] The group number is 70,030.
[CUSTOMER][POSITIVE] Amazing. This is uh uh [PII], correct?
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] Thank you. Just getting some information, bear with me updated.
[CUSTOMER][NEUTRAL] OK. [PII].
[CUSTOMER][NEUTRAL] Uh just a second.
[CUSTOMER][NEUTRAL] I have Care first, Carrington. Got that. OK. What about uh the
[CUSTOMER][NEUTRAL] Claims mailing address, please.
[AGENT][NEUTRAL] It'll be addressed to [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Do appreciate that. Thank you so much. Now, do you accept assignment of benefits to a non-participating provider?
[AGENT][NEUTRAL] Yes we do. This policy is a PPO as well, even if the member does not, the member does not have to utilize a car to network provider.
[CUSTOMER][POSITIVE] Great. The benefits
[CUSTOMER][POSITIVE] Thank you so much. If benefits are exhausted, do participating provider discount supply?
[AGENT][NEUTRAL] Um, yes, they still do. It's based on user and customary.
[CUSTOMER][POSITIVE] Amazing. For non-covered services, do participating provider discount supply?
[AGENT][NEUTRAL] No.
[CUSTOMER][POSITIVE] Great. What if the patient is not eligible for services? Do participating provider discounts apply?
[AGENT][NEUTRAL] Yes, if you're in network, yes, it does apply.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Amazing. Thank you so much. Now, as you told me, the annual max is $500. Nothing has been used, correct?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] The member has not utilized any of her benefits for [PII] or me her deductible.
[CUSTOMER][POSITIVE] Thank you. This is
[CUSTOMER][NEUTRAL] OK. And the uh this is the calendar year plan, correct?
[AGENT][NEUTRAL] Yes, from January to December.
[CUSTOMER][POSITIVE] Amazing. Just wanted to verify the deductibles. Uh, is it $50?
[AGENT][NEUTRAL] The deductible is $50 per insured up to $150 per family.
[CUSTOMER][POSITIVE] Thank you so much. What about
[AGENT][NEUTRAL] Our policy.
[CUSTOMER][NEUTRAL] Thank you. What about orthodontics? Is this patient eligible for orthodontics?
[AGENT][NEGATIVE] Not cover.
[CUSTOMER][NEUTRAL] What about uh coinsurance or preventative basic and major services, please?
[AGENT][NEUTRAL] The preventative is covered at 100 and basic is covered at 80. Just the policy does not cover major endoperoprosthesis or surgery, crowns, bridges, orthoperio, none of that is covered under the policy.
[AGENT][NEGATIVE] Dentures, partials. None of that is covered.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] Doing this
[CUSTOMER][NEUTRAL] OK. What about simple extractions? Are simple extractions covered on this policy?
[AGENT][NEUTRAL] instruction.
[AGENT][NEUTRAL] It's covered on the basic at 80%.
[CUSTOMER][NEUTRAL] Thank you. Now, even P maintenance and SRPs are not covered, correct?
[AGENT][NEUTRAL] What procedure code is that?
[CUSTOMER][NEUTRAL] Uh, for pre maintenance we can use 4910.
[AGENT][NEUTRAL] Per your maintenance is not covered.
[CUSTOMER][NEUTRAL] And what about 434?
[AGENT][NEUTRAL] What is your procedure called? not covered.
[CUSTOMER][POSITIVE] Thank you. Any missing tooth cloths and waiting period?
[AGENT][MIXED] There is a missing tooth cloth, however, there is no waiting period.
[CUSTOMER][POSITIVE] Thank you so much. Now, coming to the last set of questions, I do have some codes with me. If you can please help me with the frequency and the age limits.
[AGENT][NEUTRAL] What is your first call?
[CUSTOMER][NEUTRAL] Sure. The postcode is [PII].
[AGENT][NEUTRAL] 0120, preventative 100%.
[AGENT][NEUTRAL] Maximum of one time per tooth.
[CUSTOMER][NEUTRAL] In a year?
[AGENT][NEUTRAL] Um, hold on, I'm sorry. You said, give me that procedure code again, it's D0120?
[CUSTOMER][POSITIVE] Correct, exams.
[AGENT][NEUTRAL] OK, so that is, I don't know why I gave you the limitation.
[AGENT][NEUTRAL] Limited to two or evaluation procedures, any combination of D0120, D0140, D0150, D0160 per 12 month period.
[CUSTOMER][NEUTRAL] Thank you. What about 11:10?
[AGENT][NEUTRAL] 11.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Falls on the preventative at 100%, maximum of 1 procedure for 6 months.
[CUSTOMER][NEUTRAL] Thank you. What about 0274?
[AGENT][NEUTRAL] 274.
[CUSTOMER][NEUTRAL] By drinks
[AGENT][NEUTRAL] Bite wings, prevented of 100% once every 12 months.
[CUSTOMER][NEUTRAL] Amazing. What about 0.
[AGENT][NEUTRAL] Limited to
[AGENT][NEUTRAL] Limited to one bite wing X-ray procedure B02700272 and D0274 for 12 month period.
[CUSTOMER][NEUTRAL] Uh, yes.
[CUSTOMER][NEUTRAL] Thank you. What about 0210?
[AGENT][NEUTRAL] 0210.
[AGENT][NEUTRAL] What is your description of that cold?
[CUSTOMER][NEUTRAL] Uh, it's full mouth X-ray.
[AGENT][NEGATIVE] Falls on the basic at 80%.
[AGENT][NEUTRAL] Limited to one X-ray procedure of D0210 D0277, and D0330 per five year period.
[CUSTOMER][POSITIVE] Amazing. What about fluoride 1208?
[AGENT][NEUTRAL] Fluoride varnish is not covered, however, regular fluoride.
[AGENT][NEUTRAL] Files on the preventative at 100%.
[AGENT][NEUTRAL] Maximum of 1 procedure for 12 months, limited to dependent children aged [PII].
[CUSTOMER][NEUTRAL] OK. So,
[CUSTOMER][POSITIVE] Thank you so much. What about 0431?
[AGENT][NEUTRAL] 04.
[AGENT][NEUTRAL] What is your description of that code?
[CUSTOMER][NEUTRAL] Uh, it's oral cancer screening.
[AGENT][NEGATIVE] Not covered under the policy.
[CUSTOMER][NEUTRAL] Thank you. What about 1351?
[AGENT][NEUTRAL] 1351 C links falls on the preventative at 100% BD.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Maximum of 1 procedure for 36 months limited to dependent children under the age of [PII]. Application made to permanent molar teeth only.
[CUSTOMER][POSITIVE] Great. Do we have any downgrades on fillings on, in this policy?
[AGENT][POSITIVE] No downgrades.
[CUSTOMER][NEUTRAL] Is predetermination mandatory or suggested?
[AGENT][NEUTRAL] No.
[CUSTOMER][POSITIVE] Great. What about, uh, if you can please spell me your name?
[AGENT][NEUTRAL] My name is [PII]. today is that as a reference just because we don't provide reference numbers.
[CUSTOMER][POSITIVE] Do understand that. Great. So thank you so much, [PII] for helping me today.
[AGENT][NEUTRAL] Is there anything else that I can assist you with?
[CUSTOMER][POSITIVE] Uh, no, ma'am. Thank you so much for being so helpful today. Have a blessed day ahead. Bye-bye.
[AGENT][POSITIVE] Thanks for calling APA. You have a great one as well, [PII]. Goodbye.