AccountId: 011433970860
ContactId: 76898b31-4292-452c-b378-8e58465ee366
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 984039 ms
Total Talk Time (AGENT): 369174 ms
Total Talk Time (CUSTOMER): 231935 ms
Interruptions: 2
Overall Sentiment: AGENT=0, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/17/76898b31-4292-452c-b378-8e58465ee366_20250417T15:05_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, yes, ma'am. I'm calling to um see what a patient's coverage is for a certain procedure.
[AGENT][POSITIVE] OK. I can help you with benefits for a patient.
[CUSTOMER][NEUTRAL] I submitted
[AGENT][NEUTRAL] Can I please get your.
[CUSTOMER][NEUTRAL] Yeah, I submitted a pre-treatment estimate too, and I don't know if you'll receive that.
[AGENT][NEUTRAL] OK, alright, let's look real quick and can I please get your name and your callback number just in case the call gets disconnected?
[CUSTOMER][NEUTRAL] [PII] and it's [PII].
[AGENT][NEUTRAL] Thank you, Ms. [PII]. And what is the name of the facility you're calling for?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. And then may I get the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Um, it's [PII]. His date of birth is [PII], and the, uh, policy number is 00615476.
[AGENT][NEUTRAL] OK, let me look up that policy real quick.
[CUSTOMER][NEUTRAL] I'll be here.
[AGENT][NEUTRAL] OK. And when did you submit the pre-treat, ma'am?
[CUSTOMER][NEUTRAL] Um, that was submitted, um, on.
[CUSTOMER][NEUTRAL] What do
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, let me look real quick.
[AGENT][NEUTRAL] And it, uh, was for procedure 02751?
[AGENT][NEUTRAL] And procedures 239.
[CUSTOMER][NEUTRAL] Yes, in 3.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see if they've got any update on that pretreat.
[AGENT][NEUTRAL] Yeah, we're showing um looking at it I'm showing that.
[AGENT][NEUTRAL] We've received it. Let me see if there's any remarks.
[AGENT][NEUTRAL] On the pre-treat.
[AGENT][NEUTRAL] OK, so looking at the pre-treat.
[AGENT][NEUTRAL] That was sent in there's a remark on there that it was a pre-treat statement and uh it's not a guarantee of payment showing that the total benefit was 0.
[AGENT][NEUTRAL] To be paid.
[CUSTOMER][NEUTRAL] OK, and why is that?
[AGENT][NEUTRAL] For those two procedures.
[AGENT][NEUTRAL] Did you get a fax back with the um insured's benefit breakdown and fee schedule?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I, I got the insurance benefit breakdown but not the fee schedule. um, why wasn't this, uh, pre-treatment approved?
[AGENT][NEUTRAL] You did, OK.
[AGENT][NEUTRAL] OK, that's something that we'll have to go ahead and ask a claims um specialist about. I can get your name and number and send in a request for a claims specialist to call you back.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Would that, OK, and Miss [PII]?
[AGENT][NEUTRAL] Is the number that you gave me the [PII] a good callback number for the claims specialist to call you?
[CUSTOMER][NEUTRAL] Yes, does he like not have benefits for these codes? Is that what's happening? I mean, he's getting the work done, so I just wanted to try and see what his portion would be because he's gonna ask about it, um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Let me see what the fax back says because if it's a procedure that's not on the fax back then it's not covered, um, according to our fax back. So let me look and see if the fax back has those procedure codes on it.
[AGENT][NEUTRAL] It's gonna be just a minute so I can search it.
[AGENT][NEGATIVE] Neither one of those procedure codes are um showing up on the fax back that was sent.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, because I have it in front of me and it looks like under restorative major I'm seeing 2751 crown porcelain fused to predominantly based metal for a benefit amount of 220.
[AGENT][NEUTRAL] OK, let me look real quick. I might be overlooking it. I apologize.
[AGENT][NEUTRAL] And you said it was under restorative?
[CUSTOMER][NEUTRAL] Um, it's under restorative major.
[AGENT][NEUTRAL] And you said it was the
[CUSTOMER][NEUTRAL] The um.
[AGENT][NEUTRAL] 2751.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] For 2:20, but um.
[AGENT][NEUTRAL] OK, I
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] I see 2791.
[CUSTOMER][NEUTRAL] Uh, no, I have under, um, page, it looks like on the fax back it was page 11.
[AGENT][NEUTRAL] I do see uh page 11 and it's the third one down and it's a code 2791.
[CUSTOMER][NEUTRAL] And I got
[CUSTOMER][NEUTRAL] OK, on 2791, it is 123 up from that.
[AGENT][NEUTRAL] 2752.
[CUSTOMER][NEUTRAL] No one up from 2752 on the fax back.
[AGENT][NEUTRAL] 00 12751. OK, yes, I do see that. It might be that they hadn't processed the um pre-treat yet.
[AGENT][NEUTRAL] Let me go ahead and transfer you on over to a claims specialist so that they can go over this with you as far as the pretreat goes because what I'm seeing on the pretreat and what you and I both are seeing on the fax back is not adding up so let me go ahead and transfer you on over to a claims examiner so that they can further assist you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] OK, thank you so much. It's gonna be a brief hold while I transfer you over.
[CUSTOMER][NEUTRAL] Referring.
[CUSTOMER][NEUTRAL] Calling APL, this is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi, [PII], this is [PII] in the care team. I've got um a provider on the phone. Her name is [PII].
[AGENT][NEUTRAL] She is calling about policy number 615476. She sent in a pre-treats, uh, let me give you the number, the claim number 359-027-6.
[AGENT][NEUTRAL] Are you still there? Oh, she hung up. What in the world? OK, we'll have to call her back. I've got her number, but anyway, on the pre-treat, it is showing that 0.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Benefit would be paid $0 for the benefit.
[AGENT][NEUTRAL] So she asked me why would it be 0, because on the facts back on page 10.
[AGENT][NEGATIVE] The last one, the last code on page 10 of the fax back is 2751 and it shows it pays $220 and she said it shouldn't be $0 if we're showing on the fax back that it pays $220 and she had further questions about.
[AGENT][NEUTRAL] The pre-treat that she sent in.
[CUSTOMER][NEUTRAL] OK, let me get the document pulled up so I can see what you're looking at.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I had to look over it with her too and she did point it out and it is there.
[AGENT][NEUTRAL] And let me give you her callback number too since we're gonna have to call her back since she hung up.
[CUSTOMER][NEUTRAL] Yeah, I have to look at it and see what's going on with it and get somebody in in dental to reach out to them.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I'm not even able to pull up what you're looking at let me see.
[CUSTOMER][NEUTRAL] No documents attached to this claim, so let me look through each document here.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Male was on.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Punched the wrong button.
[CUSTOMER][NEUTRAL] OK you said uh it was a pre-treat is out here. I'm not finding it. I see the claim.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] It's a
[CUSTOMER][NEUTRAL] But I don't see the correspondence.
[AGENT][NEUTRAL] Yeah, the pre-tre number is 359-027-6.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] With the, the code the D701.
[AGENT][NEUTRAL] At the end.
[CUSTOMER][NEUTRAL] Yeah, but you said that they, the fax back is out here in in here as well, the correspondence they sent back the fax back they sent back.
[AGENT][NEUTRAL] No, the fax back, the fax back is on the SharePoint.
[CUSTOMER][NEUTRAL] Oh, OK, so she's just referring to that.
[AGENT][NEUTRAL] Right, which is what we send them to verify benefits.
[CUSTOMER][NEUTRAL] OK, let me go out here and look.
[AGENT][NEUTRAL] Oh, did I just say that.
[CUSTOMER][NEUTRAL] And that's uh 2751.
[CUSTOMER][NEUTRAL] 23.
[CUSTOMER][NEUTRAL] I do see the 2751 on there, the 2392392.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I don't
[CUSTOMER][NEUTRAL] C. 2392.
[AGENT][NEUTRAL] Yes, I didn't see that one either.
[AGENT][NEUTRAL] But I did see the
[AGENT][NEUTRAL] The 2751.
[CUSTOMER][MIXED] OK, but you said she received something it wouldn't be covered from us?
[AGENT][NEUTRAL] So under the the claim under the claim and M track when on the uh pre-treat when you click on it, the remarks state that it's.
[CUSTOMER][NEUTRAL] The 2751.
[AGENT][NEUTRAL] A pre-treat and benefits are not guaranteed, but on the claim itself up at the top where you would see where the payable would be, it's 0.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] When you click on it in M track and you look at the top where the payable would be, it says 0.
[CUSTOMER][NEUTRAL] OK. Does it normally have an amount? Cause I, I'm gonna have to check with dental cause I'm new to this dental thing cause I normally don't do dental. So, uh, I'll have to clarify with you with dental. I'm gonna have to get with [PII].
[AGENT][NEUTRAL] Yes, and I am too. I am too. We just started, we just.
[AGENT][NEUTRAL] Yes, and then if somebody.
[AGENT][NEUTRAL] OK, and if somebody could call her.
[CUSTOMER][NEUTRAL] And see if she can clarify. Is it normally the, yeah, I have to see.
[AGENT][NEUTRAL] Well, this is new. We just started doing the dental cue this week, so this is new also.
[CUSTOMER][NEUTRAL] As far as on the pre-treatment.
[CUSTOMER][NEUTRAL] But I'll, I'll check into it and see.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what's the callback number?
[AGENT][NEUTRAL] Her callback number is [PII].
[AGENT][NEUTRAL] [PII] and her name is [PII].
[CUSTOMER][NEUTRAL] OK, I will get with [PII] to see if she can give her a call back regarding that and get some clarification.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right. Thanks.
[AGENT][POSITIVE] You're very welcome. Thank you so much for helping me.
[CUSTOMER][POSITIVE] Oh, you're welcome.
[AGENT][NEUTRAL] All right, bye bye.
[CUSTOMER][NEUTRAL] Mm bye.