AccountId: 011433970860
ContactId: 5f02eaa7-bc2a-451f-86fe-99e705b5043b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1186910 ms
Total Talk Time (AGENT): 373067 ms
Total Talk Time (CUSTOMER): 389029 ms
Interruptions: 4
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/5f02eaa7-bc2a-451f-86fe-99e705b5043b_20250109T15:25_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey, [PII], good morning. This is [PII], and I'm calling you on behalf of a dental office on the record recorded line. I would like you to help me with the patient eligibility and benefits. But before that, can I have your good name and your last name initial, [PII]?
[AGENT][NEUTRAL] My name is [PII] The first initial to my last name is [PII].
[CUSTOMER][POSITIVE] Hey [PII], how are you doing today?
[AGENT][POSITIVE] I'm doing good, [PII] how are you?
[CUSTOMER][POSITIVE] I'm doing good. Thank you for asking. And, and now, let's go ahead and verify the patient eligibility and benefits. So just a moment.
[AGENT][NEUTRAL] Well, first, hold on. May I have a good contact number in case we're disconnected and the member's policy number?
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] Surely, you can reach me directly on [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Uh, it's a direct line number. We don't have extensions for this. And yes, the member ID I'm having is.
[CUSTOMER][NEUTRAL] 02450886
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII]. First name, [PII] Last name, [PII]. With the date of birth, that is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So I am showing the policy is active. It's been effective since [PII].
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And did you need a copy of the fax back sent over to you or you have particular questions?
[CUSTOMER][POSITIVE] No, thank you so much for the information and I really appreciate that, [PII], but uh I'm already having the breakdown with me, so I have some specific questions and I want you to help me with that.
[AGENT][NEUTRAL] That's fine.
[AGENT][NEUTRAL] What's the questions that you have?
[CUSTOMER][NEUTRAL] OK, so [PII]
[CUSTOMER][NEUTRAL] OK, no worries. So, uh, and I, can you first of all, help me like, is it a calendar plan or a benefit you want?
[AGENT][NEUTRAL] It's a calendar year um plan.
[CUSTOMER][NEUTRAL] 29979.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Coordination of benefits reading.
[AGENT][NEUTRAL] There's no coordination of benefits?
[CUSTOMER][NEUTRAL] OK. Are we in-network with you or out of network? Do you pay for out of network benefits as well, and what is the fee schedule that is to follow?
[AGENT][NEUTRAL] OK, so to confirm if you're in or out of network, I can give you the number to Carrington to confirm that. The benefits are the same whether the provider is in or out of network, and what was the last question?
[CUSTOMER][NEUTRAL] Call
[CUSTOMER][POSITIVE] OK, no worries. Thank you so much for the information. So can we use usually customer and reasonable?
[CUSTOMER][NEUTRAL] UCR as in free schedule?
[AGENT][NEUTRAL] Say that one more time.
[AGENT][NEUTRAL] This isn't on a UCR schedule. It's just on a standard fee schedule.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm, what will be the claims mailing address?
[AGENT][NEUTRAL] So it's [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] Can we use Care Platinum series?
[CUSTOMER][NEUTRAL] Or Carrington 500 series.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] In filing the claim?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Neither, you're filing it to APL.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh just a moment.
[CUSTOMER][NEUTRAL] Again, uh.
[CUSTOMER][NEUTRAL] Just a moment. Can I place your call on hold for a while, just a moment, [PII], brief couple of minutes. OK, thank you.
[AGENT][NEUTRAL] Sure. OK.
[CUSTOMER][POSITIVE] Thank you for holding the line and I really appreciate your patience, [PII]. So let's go ahead and verify the, uh, OK, can you help me to verify the group name and the group number, please?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Sure, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The group number is 70052.
[CUSTOMER][POSITIVE] Good
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The group name is Oxford Global Resources.
[CUSTOMER][POSITIVE] Thank you so much for the information and I really appreciate your help and
[CUSTOMER][NEUTRAL] Uh, uh, can you help me with the co-insurance for the primitive basics and majors?
[AGENT][NEUTRAL] So major insurance is not covered on this policy that includes endodontic, perontic, proteodontic, and oral surgery.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Preventative is covered at 100%.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] N as in November.
[AGENT][NEUTRAL] Radiographs, FMX, basic, and basic restorative are all covered at 80%.
[CUSTOMER][NEUTRAL] For the
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] November.
[CUSTOMER][NEUTRAL] So exam is, uh, OK, and
[CUSTOMER][NEUTRAL] Uh, I do believe there is no auto coverage as well.
[AGENT][NEUTRAL] There is no, say that again.
[CUSTOMER][NEUTRAL] There is no orthodontics coverage, right? Only oral surgery is covered and fixed proontics implants also.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Oral surgery, oral.
[AGENT][NEUTRAL] Can you ask the question, let me answer before you go to the next one. So, no, oral surgery is not covered, nor is orthodontics.
[CUSTOMER][POSITIVE] Mm, OK, thank you so much for the information, [PII], and I'm sorry to uh interrupt you. OK. So as of now, only preventive and basics are covered.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, does the end of period surgical, non-surgical, everything is not covered, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so nothing is covered apart from the basics, uh, uh, preventative and basics. So can you help me with the quotes? I have some quotes. And before that, I want you to help me with the uh benefits of the plan like what are the
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Deductibles, family deductibles, are they met or not? What is the maximum amount, uh, is it, or what is the accumulation of the use amount out of it?
[CUSTOMER][NEUTRAL] And also
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][POSITIVE] No worries, please take your time.
[AGENT][NEUTRAL] OK, so on the fax back, the calendar year maximum is $500 per covered person.
[AGENT][NEGATIVE] None has been used. The deductible is $50 per person up to $150 per family, and that has not been used either for [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK, thank you so much for the information and I really appreciate it. And now, are you ready for the codes? I want you to help me with that frequency, uh, I'm sorry, let me just, uh, uh, I'm sorry to interrupt you. Uh, just give me the coinsurance frequency and the history, OK?
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] Yes, you can give them all to me at once.
[CUSTOMER][NEUTRAL] And age limit is applicable. So, let's start. The very first code is D0120.
[AGENT][NEUTRAL] OK, I have to go through the facts back for the code, so can you give them to me all at once?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, that's what I'm saying is D 0120, then D 0210.
[CUSTOMER][NEUTRAL] D. 0274.
[CUSTOMER][NEUTRAL] B 0330.
[CUSTOMER][NEUTRAL] D. 0367 D. 0431.
[CUSTOMER][NEUTRAL] D1110 D 1206 D 1208. D 1351 D 2393. That's all.
[AGENT][NEUTRAL] OK, and is it alright if I place you on a brief hold while I go through these codes?
[CUSTOMER][POSITIVE] Mhm. No worries. Please take your time.
[AGENT][NEUTRAL] You said you need the frequency limitations in history?
[CUSTOMER][POSITIVE] Yes. Yes, that's correct.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][POSITIVE] OK, no worries. Please take your time.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Uh oh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] All of this can be done on online service center.
[AGENT][NEUTRAL] If you have the tax back.
[AGENT][NEGATIVE] I wish they gave was history.
[AGENT][NEUTRAL] But OK.
[AGENT][NEUTRAL] 0120.
[AGENT][NEUTRAL] Um, preventive 100.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I'm just gonna order because then I'm gonna confuse myself.
[AGENT][NEUTRAL] 210.
[AGENT][NEUTRAL] 2
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yep, I am.
[AGENT][NEUTRAL] OK, what is it 036.
[AGENT][NEUTRAL] Because he's gonna come back and say, well if there's history.
[AGENT][NEUTRAL] But I don't see this code 036.
[AGENT][NEGATIVE] Covered 431 not covered.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Not covered 12. 0 wait, wait, wait, wait, wait. Oh no, I'm in the right place. So 6 not covered, 1208 not covered. 1351 CLN.
[AGENT][NEUTRAL] 100.
[AGENT][NEUTRAL] PDE.
[AGENT][NEUTRAL] 23.
[AGENT][NEUTRAL] 93.
[AGENT][NEUTRAL] 7 BR 80.
[AGENT][NEUTRAL] E
[AGENT][NEUTRAL] Oh, Travis.
[CUSTOMER][NEUTRAL] Yes, I'm here. I'm here.
[AGENT][POSITIVE] Alright, thank you so much for holding. I apologize for that wait. So for code 0120.
[CUSTOMER][POSITIVE] You're welcome, ma'am.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] It's covered, um, it's preventative, so it's covered at 100%.
[AGENT][NEUTRAL] There's no history on file?
[CUSTOMER][NEUTRAL] One
[AGENT][NEUTRAL] And it's limited to two oral evaluation procedures in any combination with um it it's paired with 120, 40, 50, and 60 per 12-month period.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] You're welcome. Code 0210, radiograph and FMX covered at 80% under basic.
[AGENT][NEUTRAL] Limited to one X-ray procedure per five-year period, and there's no frequency or there's no history on file for that?
[CUSTOMER][POSITIVE] Thank you so much. What about the buy drinks?
[AGENT][NEUTRAL] 00274. History on file is for [PII].
[CUSTOMER][NEUTRAL] How much
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Fight wings are covered at 100% once per 12-month period.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] 0330.
[AGENT][NEGATIVE] Radiograph and FMX is 80%, limited to one X-ray procedure per 5-year period. There's no history on file for that code.
[CUSTOMER][NEUTRAL] And right now.
[AGENT][NEUTRAL] 0367.
[AGENT][NEUTRAL] History on file is for [PII].
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And that is not a cover code.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] You're welcome. 0431 is not covered.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 01101110. Um, proffe are at 100% and there's no history on file.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK, I'm sorry about it.
[AGENT][NEUTRAL] It's OK. That's a once, once every 6 months.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 1206 and 1208 are not covered codes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 1351 sealants are preventative at 100%.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Maximum of 1 procedure per 36 months.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Limited to dependent children under age [PII].
[CUSTOMER][NEUTRAL] OK, for the ills, the age limit is [PII].
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And for the 12061208, what is the limit?
[AGENT][NEGATIVE] They're not covered.
[CUSTOMER][NEUTRAL] OK. And uh is there any history about children?
[AGENT][NEUTRAL] OK, hold on one moment. There's one more uh limitation. Did you need that for 1351?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so applications made to permanent molar teeth only.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] There's no history on file for 1351.
[CUSTOMER][NEUTRAL] And also.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 2393.
[AGENT][NEGATIVE] Um, resin is under basic restorative at 80%. There's no, there's no history on file.
[AGENT][NEUTRAL] Replace existing only if in place for 24 months?
[AGENT][NEUTRAL] A maximum of 1 each tooth per 24 months.
[CUSTOMER][NEUTRAL] OK. And can you help me for the feelings? Are they covered or they are downgraded?
[AGENT][POSITIVE] There's no downgrades.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, thank you so much for all the information you provided me, [PII], and I really appreciate it.
[CUSTOMER][POSITIVE] And all the information provided by you is very useful to me. So, as of now, that's all for today for this particular patient, and I really appreciate all your
[CUSTOMER][NEUTRAL] Uh, help and information provided by you. So before we proceed any more further and end of this call, can you help me with the call reference number to call for this particular patient?
[AGENT][POSITIVE] You're very welcome.
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. First initial to my last name is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII] to this date, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK, thank you so much, [PII]. I really appreciate it. Bye-bye. Take care. Have a great day ahead.
[AGENT][POSITIVE] Thank you, thanks for calling APL and um I hope you have a great day and happy New Year.
[CUSTOMER][POSITIVE] Happy New Year [PII] bye bye.
[AGENT][NEUTRAL] Bye bye.