AccountId: 011433970860
ContactId: 6a1635ba-c4d5-4dae-a3ec-131322d76a13
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 587150 ms
Total Talk Time (AGENT): 245590 ms
Total Talk Time (CUSTOMER): 163114 ms
Interruptions: 1
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/6a1635ba-c4d5-4dae-a3ec-131322d76a13_20250226T16:54_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, I was calling to see if I could get a breakdown of the patient's policy, please.
[AGENT][POSITIVE] Mhm, sure, I can assist you with that. Can I have your name and a callback number?
[CUSTOMER][NEUTRAL] Uh, [PII] callback number is [PII].
[AGENT][POSITIVE] Thank you, [PII].
[AGENT][NEUTRAL] Can I have the policy number of the member that you're inquiring eligibility for today?
[CUSTOMER][NEUTRAL] Um, it's 02596195.
[AGENT][NEUTRAL] Could you verify the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Um, it is.
[CUSTOMER][NEUTRAL] Uh, for [PII], date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And you're calling to request afa back of benefits or you want it verbally?
[CUSTOMER][NEUTRAL] Uh, can I go ahead and get it verbally?
[AGENT][NEUTRAL] Sure, this member's policy has been active since [PII] and is currently active. This member has 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 guarantee of benefits, [PII], just a disclaimer of the policy's coverage. The policy covers preventative at 100% and basic at 80%. Unfortunately, major endo periorosthesis or surgery crowns bridges ortho.
[AGENT][NEUTRAL] Surgical procedures. Anything perio endo, anything considered as major, it won't be covered under the policy.
[AGENT][NEGATIVE] It's very limited.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And then this plan doesn't have a family deductible, correct? You just said it was an individual.
[AGENT][NEUTRAL] There's a, it's a $50 deductible per insured up to $150 per family. It does not apply to us preventative services.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, and then I'm assuming it runs on a calendar year.
[AGENT][NEUTRAL] Yes, it is correct from January to December.
[CUSTOMER][NEUTRAL] Is there a waiting period or missing tooth cloths?
[AGENT][NEGATIVE] There is no waiting period, [PII]. However, there is a missing tooth cloth and I'm not sure I'm just don't understand why there is a missing tooth cloth cause nothing is major is covered under the policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, does this plan have Ortho benefits?
[AGENT][NEGATIVE] It does not. As stated prior to the list of procedures that's not covered, so ortho, perio, Edo, major, crowns, bridges, dentures, partials, none of that is covered under the policy.
[CUSTOMER][NEUTRAL] OK, and then can I go ahead and give you codes for frequencies?
[AGENT][NEUTRAL] What is your first cold?
[CUSTOMER][NEUTRAL] Um, it's 0 120.
[AGENT][NEUTRAL] It is considered as or evaluation falls on a preventative at 100%.
[AGENT][NEUTRAL] 2 for 12 month period limitations are as follows.
[AGENT][NEUTRAL] Limited to 2 or evaluation procedures in any combination of D0120 D0140 D0150 and D0160 for 12 month period.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK perfect.
[CUSTOMER][NEUTRAL] Um, the next would be 11:20.
[AGENT][NEUTRAL] What is your description of the code?
[CUSTOMER][NEUTRAL] Uh, prophylaxis.
[AGENT][NEUTRAL] Falls on the preventative at 100%, maximum of 1 procedure per 6 months, limited to dependent children aged [PII].
[CUSTOMER][NEUTRAL] OK, um, next would be uh 1208 for flooring.
[AGENT][NEUTRAL] It's still with varnish or without?
[CUSTOMER][NEUTRAL] Uh, let me see.
[CUSTOMER][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] I believe with.
[AGENT][NEUTRAL] With is not covered without falls on a preventative at 100%.
[AGENT][NEUTRAL] Maximum of 1 procedure per 12-month period, limited to dependent children under the age of [PII].
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] You said not covered for without correct?
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, next would be 0272, uh, by wings.
[AGENT][NEUTRAL] Preventative 100%.
[AGENT][NEUTRAL] Limitations are as follows, limited to two, limited to one bite wing X-ray procedure of D0270, B0274, and D0272.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, and then, um.
[CUSTOMER][NEUTRAL] It'd be 0 to 10 for um SMX X-ray.
[AGENT][NEUTRAL] 2.
[CUSTOMER][NEUTRAL] full miles.
[AGENT][NEGATIVE] Falls on the basic at 80%.
[AGENT][NEUTRAL] Limited to one X-ray procedure of D010, D0277 and D0330 per five year period.
[CUSTOMER][POSITIVE] Perfect. Um, how about 1351 Selans?
[AGENT][NEUTRAL] Present files on a preventative at 100%.
[AGENT][NEUTRAL] Mm.
[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][NEUTRAL] OK, um, 2392, uh, for resin based composite.
[AGENT][NEUTRAL] Basic 80%.
[AGENT][NEUTRAL] Replace existing only if in place for 24 months, maximum of 1 each 2 for 24 months.
[CUSTOMER][NEUTRAL] Does the downgrade?
[AGENT][NEUTRAL] No downgrade.
[CUSTOMER][NEUTRAL] OK, um, that would be 1510 space maintainer.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] Preventative 100%.
[AGENT][NEUTRAL] Limited to dependent children under the age of [PII].
[AGENT][NEUTRAL] Maximum of one per lifetime per quadrant or arch.
[CUSTOMER][NEUTRAL] Um, 9110 palliative.
[AGENT][NEUTRAL] Falls on the preventative, I'm sorry, falls on the basic at 80%, no limitation.
[CUSTOMER][NEUTRAL] Um, next would be 90 to 30 for uh nitrous oxide or yeah.
[AGENT][NEGATIVE] Not covered. It's considered as major.
[CUSTOMER][NEUTRAL] OK, and then that night guard would also not be covered.
[AGENT][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] Also not cover you for sinectomy. OK, um, next will be 9310 for consultation.
[AGENT][NEUTRAL] Falls on the basic 80%, no limitation.
[CUSTOMER][NEUTRAL] 80% um next would be 1354 for silver damine fluoride.
[AGENT][NEUTRAL] 1354.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEGATIVE] It's not covered under the policy.
[CUSTOMER][NEUTRAL] OK, and then last one that also wouldn't be covered.
[CUSTOMER][NEUTRAL] Um, how about 1352?
[AGENT][NEUTRAL] Mm, what is your description of 1352, [PII]?
[CUSTOMER][NEUTRAL] Um, it's a preventative res, uh, actually let me see.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] RR
[CUSTOMER][NEUTRAL] It's preventative resin restoration and a moderate to high carries risk patient.
[AGENT][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, can I go ahead and get a group number, uh, I'm sorry, a group name for this plan and then, um, a reference number for the call?
[AGENT][NEUTRAL] The group name is Creative Circle.
[AGENT][NEUTRAL] LLC.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK and then um can I get a call reference number please?
[AGENT][NEUTRAL] We don't provide those, [PII], however, you can use my name in today's date as a reference. It's [PII].
[CUSTOMER][POSITIVE] OK perfect thank you so much.
[AGENT][POSITIVE] You're welcome thanks for calling APL and have a great day.
[CUSTOMER][NEUTRAL] You too bye.