AccountId: 011433970860
ContactId: 6eec0840-6613-46fb-ae01-9d4c18f1b787
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 604229 ms
Total Talk Time (AGENT): 172745 ms
Total Talk Time (CUSTOMER): 181154 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/6eec0840-6613-46fb-ae01-9d4c18f1b787_20250428T19:57_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello [PII], my name is [PII]. I'm calling from [PII] office. Um, I'm calling to see, uh, if you can give me eligibility and benefits for one of your members.
[AGENT][NEUTRAL] Hi, [PII], yes, I can help with eligibility and benefits. Do you have the policy number of the member?
[CUSTOMER][NEUTRAL] Yes, policy number is 021-948-38.
[AGENT][NEUTRAL] And patient name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII], um, [PII] I'm sorry [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You have a good callback number, [PII] just in case we're disconnected.
[CUSTOMER][NEUTRAL] Yes, um, [PII].
[AGENT][NEUTRAL] OK, and I can send a fax back or we can go over it on the phone. Is there a preference?
[CUSTOMER][NEUTRAL] Um, can you just, uh, can we do it over the phone? That'll be better.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you I appreciate it um and can you tell me if we're in network with this um with this insurance we have, we haven't worked with you guys before that I can't remember.
[AGENT][NEUTRAL] Um, let me see, see if there's a network.
[AGENT][NEUTRAL] Um, they don't have a network, we just pay off what's reasonable and customary.
[CUSTOMER][NEUTRAL] OK, and how would I find out if uh we are in like how much would you if you guys start paying our standard fees, can we go over the fees or you guys will send me?
[CUSTOMER][NEUTRAL] Your fees.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] We just pay, you know, based on what's reasonable and customary. Are you needing to go over several codes or what what are you needing?
[CUSTOMER][NEUTRAL] Uh, well, it's for a child, so we do have, um, like pediatric codes if we can go over them, that's, that'll be great. Is this through an employer or is this uh self pay?
[AGENT][NEUTRAL] That's employer.
[CUSTOMER][NEUTRAL] Employer, what's the employer's name?
[AGENT][NEUTRAL] Her name is Universal Trucking.
[CUSTOMER][NEUTRAL] For trucking thank you and what's um the group number or plan number?
[AGENT][NEUTRAL] 15844.
[CUSTOMER][NEUTRAL] Thank you and the insurance address?
[AGENT][NEUTRAL] Claims address is [PII].
[AGENT][NEUTRAL] 73124-8950
[CUSTOMER][NEUTRAL] OK, and what's the effective date?
[AGENT][NEUTRAL] The effective date of the policy is [PII].
[CUSTOMER][NEUTRAL] OK, and is there a maximum and deductible?
[AGENT][NEUTRAL] your maximum is $1500 and this is not a guarantee of payment. It's a basic outline of the policy. Deductible is $50 does not apply to preventive services.
[CUSTOMER][NEUTRAL] OK, and is this a calendar year or fiscal?
[AGENT][NEUTRAL] Calendar.
[CUSTOMER][NEUTRAL] Calendar thank you. Can you give me a percentage for preventative basic major?
[AGENT][NEUTRAL] Preventative is 100%. Radiographs, which includes FMX expenses, basic expenses, and basic restorative pay 80%.
[AGENT][NEUTRAL] Major pays 40%. That does include endodontics, periodontics, and prosthodontics, and oral surgery. It's all under major, and there's a 12-month waiting period for major.
[CUSTOMER][NEUTRAL] OK, so he already met her, right? [PII] since, since [PII]?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, perfect, thank you. um, exam, uh, proffe fluoride X-rays, can you give me the frequency and um coverage please?
[AGENT][NEUTRAL] Trophies and cleanings are once every 6 months. That's under preventive. Fight wings are once every 12 months. That's under basic.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Full mouth X-ray and panel once every 5 years under basic, crowns and bridges once every 7 years, and partial dentures once every 5.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK, and uh 20,220, the per optical X-rays, is that on the basic and does it have a frequency?
[AGENT][NEUTRAL] Uh, let me see one moment.
[AGENT][NEUTRAL] Um, that's under basic. There's no frequency.
[CUSTOMER][NEUTRAL] OK, and fluoride, is there a frequency for fluoride and age limit?
[AGENT][NEUTRAL] And fluorides that are preventive, and that is
[AGENT][NEUTRAL] I'm limited to dependent children under age [PII].
[CUSTOMER][NEUTRAL] On the 14. I'm sorry, you said once every 6 months or every 12 months?
[AGENT][NEUTRAL] Uh, the fluoride, I'm looking, hold on one moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] It's
[AGENT][NEUTRAL] Once every 12 months.
[CUSTOMER][NEUTRAL] Thank you. Um, the 0140, the emergency exam, does it show frequency with all the other exams?
[AGENT][NEUTRAL] Yes, it does, uh, 2 for 12 months.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, and is there an 80 80% or 100%?
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] It's at 80%.
[CUSTOMER][NEUTRAL] 80 thank you. Are we allowed to do treatment on the same day?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, OK, and for the [PII], what's the age limit for that for the child profy?
[AGENT][NEUTRAL] Children under [PII].
[CUSTOMER][NEUTRAL] OK, thank you, um, ceilings and space maintainer is that a cover service?
[AGENT][NEUTRAL] Uh, space maintainers are covered under preventive as well as sealants.
[AGENT][NEUTRAL] And let me see what the frequency is.
[AGENT][NEUTRAL] Limited to children under age [PII]?
[AGENT][NEUTRAL] Max of one per lifetime per quadrant or arch, that's for.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] For the space maintainers.
[CUSTOMER][NEUTRAL] OK, and for seasoning does it have a frequency?
[AGENT][NEUTRAL] 136 months.
[AGENT][NEUTRAL] Molar teeth only?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Thank you. Is um 1354 a cover service?
[AGENT][NEUTRAL] I don't show it covered.
[CUSTOMER][NEUTRAL] Yeah, OK, and are composites downgraded to a mug on um poster teeth.
[AGENT][NEUTRAL] No, there's no downgrades.
[CUSTOMER][NEUTRAL] No, does it have a frequency for fillings?
[AGENT][NEUTRAL] Um let me see, hold on.
[AGENT][NEUTRAL] OK um let's see, replacement of existing max of 12th for 24 months.
[CUSTOMER][POSITIVE] OK, thank you so much. um, does this policy have any ortho benefits?
[AGENT][NEUTRAL] No, there are no Orzos.
[CUSTOMER][NEUTRAL] No or so OK. And does Harper have any history on file for exam cleaning fluoride or any X-rays?
[AGENT][NEUTRAL] Um, I'm not showing any history.
[CUSTOMER][NEUTRAL] No history? OK, thank you for that. um, now can I, can we submit the claim electronically or only through paper?
[AGENT][NEUTRAL] Uh, yes, you can do it electronically. Our payer ID is 60801.
[CUSTOMER][NEUTRAL] 60801. Perfect, thank you. Can I have a reference number for this call?
[AGENT][NEUTRAL] Uh, reference number is my name, [PII], first initial to last name [PII] as [PII], and today's date. And anything else I can help with?
[CUSTOMER][POSITIVE] No, that's it thank you [PII] have a great day.
[AGENT][POSITIVE] OK, thanks for calling APL. You as well. Bye-bye.