AccountId: 011433970860
ContactId: 61ac3ff1-6b8a-4ced-905a-3c077ff1ba7e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 443359 ms
Total Talk Time (AGENT): 109449 ms
Total Talk Time (CUSTOMER): 195975 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/19/61ac3ff1-6b8a-4ced-905a-3c077ff1ba7e_20250319T22:05_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling on behalf of the dental office to check on the eligibility and benefits of a patient on a recorded call. Could you please help me with that?
[AGENT][NEUTRAL] Could you spell your name for me please?
[CUSTOMER][NEUTRAL] Sure. It's [PII]
[AGENT][NEUTRAL] And may I please have a callback number?
[CUSTOMER][NEUTRAL] [PII]. It's a direct line.
[AGENT][NEUTRAL] Can I have the policy number?
[CUSTOMER][NEUTRAL] All right, that would be 02574652.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] May I have the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] You're calling in for eligibility and benefits for this member?
[CUSTOMER][POSITIVE] You're right.
[AGENT][NEUTRAL] OK. And would you like a fax back?
[CUSTOMER][NEUTRAL] Um, sure, but before that, may I please have the effective date and the coordination of benefit?
[AGENT][NEUTRAL] OK, we don't coordinate benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] This is not
[CUSTOMER][NEUTRAL] And the effective date.
[AGENT][NEUTRAL] This is not an in or out of network policy. The effective date is showing 21 of 25.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] 25, got it. And then for, uh, just checking a few information for
[CUSTOMER][NEUTRAL] The plan maximum it is 1500 this calendar year.
[AGENT][NEUTRAL] Let me pull that up for you.
[AGENT][NEUTRAL] And verification of coverage does not guarantee the payment of the claim for this member they do have up to 1500.
[AGENT][NEUTRAL] Per calendar year max with a $50.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Per covered insured up to 150 per family.
[CUSTOMER][NEUTRAL] Got it. And nothing used on at this calendar year?
[AGENT][NEUTRAL] As of right now, Nevea has not used any of our benefits.
[CUSTOMER][NEUTRAL] Got it. And to confirm, there is no auto coverage, right?
[AGENT][NEGATIVE] Ortho is not covered.
[CUSTOMER][NEUTRAL] Got it. And there is no missing two clause or waiting period?
[CUSTOMER][NEUTRAL] Sorry, there is a missing two class. um.
[CUSTOMER][NEUTRAL] Uh, may I know about the waiting period, please?
[AGENT][NEUTRAL] On which benefit
[CUSTOMER][NEUTRAL] Uh, for the major services.
[AGENT][NEUTRAL] There is a 12 month waiting period on major expenses.
[CUSTOMER][NEUTRAL] Mhm. All right. So to confirm, 100 is for preventive, 80 is for basic, which has no waiting period, however, for major, it is 40 with 12 month waiting period.
[AGENT][NEUTRAL] Yes, do you already have the fax back for this member?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yes, that's why I just need to check your information, just to confirm.
[CUSTOMER][NEUTRAL] And then for the filling and for the crown, there is no downgrade.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] All right, for the posterior composite 2393, this is one for 24 months, right?
[AGENT][NEUTRAL] What was that called again?
[CUSTOMER][NEUTRAL] 2393.
[AGENT][NEUTRAL] It shows replacement of existing only if in place for 24 months.
[CUSTOMER][NEUTRAL] Mhm mhm 1924 months.
[AGENT][NEUTRAL] And then a maximum of 1 each tooth for 24 months.
[CUSTOMER][NEUTRAL] Got it. And then for the Crown, 2750, this is one for seven years?
[AGENT][NEUTRAL] It's showing maximum of 1 per 7 year period.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then limit it to patients aged [PII] and over.
[CUSTOMER][NEUTRAL] [PII] and over.
[CUSTOMER][NEUTRAL] OK, so, um,
[CUSTOMER][NEUTRAL] [PII] and over.
[CUSTOMER][NEUTRAL] The patient is not eligible.
[CUSTOMER][NEUTRAL] [PII]. OK, patient is eligible. And then, uh, OK, and then just to confirm here, for the exam, it is 2 to 12 months, right?
[AGENT][NEUTRAL] What is the code?
[CUSTOMER][NEUTRAL] 0 0120.
[AGENT][NEUTRAL] Limited to 2 or evaluation procedures in any combination per 12-month period.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it. For FMX and panel.
[CUSTOMER][NEUTRAL] Uh, this is under basic 80% once for 5 calendar year they share frequency.
[CUSTOMER][NEUTRAL] So the code 0210 and 0330.
[AGENT][NEUTRAL] OK, now we do have a limit on verifying codes that is the reason of the fax back.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right. Got it. All right, then, uh, to move on, uh, may I know if there's any history then for this patient for preventive services?
[AGENT][NEGATIVE] As I previously stated, the member has no benefits that's been used.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] All right, got it. So there'll be no history. Great then. So, yes, you can provide me with the fax just to make sure the information is correct. I'll provide you with the fax number.
[AGENT][NEUTRAL] OK, you said that you already have the facts back for this member.
[CUSTOMER][NEUTRAL] Yes, but, uh, this is an old fact, so I need to check if uh the information is correct. That's why I'm calling to verify.
[AGENT][NEUTRAL] May I have the fax number please?
[CUSTOMER][NEUTRAL] All right, sure. The fax number is [PII].
[CUSTOMER][NEUTRAL] I'll repeat. It is [PII].
[AGENT][NEUTRAL] And that is attention [PII]?
[CUSTOMER][POSITIVE] You're right, you can provide that.
[AGENT][POSITIVE] OK, I will get that submitted over to you. Is there anything else that I can assist you with today?
[CUSTOMER][NEUTRAL] Uh, no, and so just to check, may I know how long will it take for me to receive the fax just to have an idea.
[AGENT][POSITIVE] I'm getting ready to submit it now.
[CUSTOMER][POSITIVE] All right. Thank you so much, [PII], for your help. Have a wonderful day.
[AGENT][POSITIVE] You're welcome thank you for calling American Public Life, have a great day.
[CUSTOMER][NEUTRAL] Bye for now. All right.