AccountId: 011433970860
ContactId: 6f443eea-7c7b-4f7e-9f26-483f6791d34b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 539039 ms
Total Talk Time (AGENT): 182315 ms
Total Talk Time (CUSTOMER): 126972 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/22/6f443eea-7c7b-4f7e-9f26-483f6791d34b_20250422T12:44_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Good morning. This is [PII] calling from Enfield Family Dental. We have a patient coming for deep cleaning today, and I'd like to know if he's eligible. Could you please help me?
[AGENT][POSITIVE] Yes, I can help you today. Do you have the policy number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] 02313839.
[AGENT][POSITIVE] OK, perfect.
[AGENT][NEUTRAL] OK, [PII], what's a good call back number in case our call gets dropped?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And then the patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes. [PII] Rivera, [PII].
[AGENT][NEUTRAL] OK, just one moment while I pull up their benefits.
[AGENT][NEUTRAL] OK. So I have their policy pulled up. You were wondering about cleanings?
[CUSTOMER][NEUTRAL] Yes, the cleaning.
[AGENT][NEUTRAL] OK, so this is not a guarantee of payment, just a verification of coverage. So it looks like.
[AGENT][NEUTRAL] For preventative expenses is 100% of UCR.
[AGENT][NEUTRAL] Uh, basic expenses, 80% of UCR.
[AGENT][NEUTRAL] And then major expenses, 40% of UCR.
[AGENT][NEUTRAL] And they have a calendar year maximum of 1500 per covered insured and.
[AGENT][NEUTRAL] Cleaning is once every 6 months. Do you have a code for deep cleaning?
[CUSTOMER][NEUTRAL] Yes, it is 4341.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] OK, so this falls under 40% of UCR and there is a waiting period of 12 months.
[CUSTOMER][NEUTRAL] OK, so it's major, and then he has to wait 12 months until he can do the deep cleaning.
[AGENT][NEUTRAL] Yes, but it looks like the effective date on his policy is [PII].
[AGENT][NEUTRAL] So, he should be OK. I can look and see if he's used anything.
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Um, OK. And then that also falls under limitation, maximum of 1 each quadrant per 24 months.
[AGENT][NEUTRAL] OK, let me see if he's used that last year or this year.
[AGENT][NEUTRAL] OK, so it doesn't look like he.
[AGENT][NEUTRAL] No, he should be good.
[CUSTOMER][NEUTRAL] OK, yeah, so you said the one for, yeah, I'm sorry, go ahead.
[AGENT][NEUTRAL] He hasn't used anything.
[AGENT][NEUTRAL] Oh, no, you're fine. Go ahead.
[CUSTOMER][NEUTRAL] OK, thank you so it's 1 quarter appointment or he can do just all 41 seating.
[AGENT][NEUTRAL] Um, it says maximum of 1 each quadrant per 24 months.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] Yes, so he only can get one done every 24 months.
[CUSTOMER][NEUTRAL] What? wow, so one quad this year and next year another one, and then until you have all 4 done?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, yeah, that does sound a bit strange. Um, yeah, that's
[CUSTOMER][NEGATIVE] That's so weird.
[AGENT][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] By the time you know, go ahead.
[AGENT][NEUTRAL] Yeah, so for the code 4341, [PII] scaling and rooting planning for more contagious teeth or bonded teeth. Yeah, so it has that limitation.
[AGENT][NEUTRAL] One each quadrant, yeah.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, and it is at 40%.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, and um, I do not, do not have the fee schedule. Do you know what the schedule we're following?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I don't see the fee schedule on his.
[AGENT][NEUTRAL] Benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, would you like me to send you, send you over the fax pack?
[CUSTOMER][NEUTRAL] I would love to but uh fax machine is broken. Let me read out the claim mailing address we have for him.
[CUSTOMER][NEUTRAL] Um, it's uh [PII] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Yes, mhm, that is correct.
[CUSTOMER][NEUTRAL] OK, and what's the payer ID darling, please?
[AGENT][NEUTRAL] It is 60801.
[CUSTOMER][NEUTRAL] 01 thank you. Alrighty and do you know if we are in or out of network?
[AGENT][NEUTRAL] So this policy goes by UCR.
[CUSTOMER][NEUTRAL] UCR OK.
[AGENT][NEUTRAL] Yes. Mhm.
[CUSTOMER][NEUTRAL] And I don't know if you're able to tell me what percentage coverage the 34 4341 would be since I do not have it.
[AGENT][NEUTRAL] Sorry, what did you say in the beginning? It got kind of quiet.
[CUSTOMER][NEUTRAL] Oh sorry my dear, you said they're gonna pay 40% of the work card. Do you know 40% of how much?
[AGENT][NEUTRAL] No, um, that I guess that depends on your clinic and how much you guys charge.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] It's just 40% UCR, yeah.
[CUSTOMER][NEUTRAL] Mm, OK.
[CUSTOMER][NEUTRAL] We're gonna follow our fee, OK.
[CUSTOMER][POSITIVE] Thank you so much for your help today.
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with?
[CUSTOMER][NEGATIVE] No, thank you, help me just fine.
[AGENT][POSITIVE] Of course. Thanks for calling APL. Have a good day.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] You as well thank you.
[AGENT][POSITIVE] All right. You're welcome. Bye.
[CUSTOMER][NEUTRAL] Bye