AccountId: 011433970860
ContactId: 77219156-82c9-4492-ac85-39c885707b70
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 886169 ms
Total Talk Time (AGENT): 367695 ms
Total Talk Time (CUSTOMER): 149788 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/10/77219156-82c9-4492-ac85-39c885707b70_20250410T21:10_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Thank you for calling American Public Life. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] I'm calling to get some benefit information for our patients.
[AGENT][NEUTRAL] No, OK, I can help you with that. May I have your name and a callback number?
[CUSTOMER][NEUTRAL] [PII] [PII]
[AGENT][NEUTRAL] Thank you. The policy number you're calling on, [PII]?
[AGENT][NEUTRAL] [PII], I'm sorry.
[CUSTOMER][NEUTRAL] That's OK. 02536216.
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII]
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, thank you so much for verifying her account and you say you're calling for benefit information?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] How can I help you?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I'm calling to see how much extractions are covered.
[AGENT][NEUTRAL] OK, let me get.
[CUSTOMER][NEUTRAL] Simple surgical and impacted teeth.
[AGENT][NEUTRAL] OK, hold one moment.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 01 moment.
[AGENT][NEUTRAL] OK. And do you have a uh procedure code, particular procedure code? OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I have the I have a few of them. Do you want them all that one?
[AGENT][NEUTRAL] No, just one at a time.
[CUSTOMER][NEUTRAL] OK, um, 7210.
[AGENT][NEUTRAL] 7210. I do not show 7210 it is a cover procedure.
[CUSTOMER][NEUTRAL] Yeah, or D 7210.
[CUSTOMER][NEUTRAL] You don't have to pay you to be.
[AGENT][NEUTRAL] Let me make sure and go back through the codes.
[AGENT][NEUTRAL] No, I have 7140. That's the only extraction I'm showing.
[CUSTOMER][NEUTRAL] OK, and how is 7140 covered?
[AGENT][NEUTRAL] 7410 let's see, extraction erupted tooth or exposed root and let me see what the exclusion on that is or the limitation.
[CUSTOMER][NEUTRAL] I yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Oh wait let me see, 7210. I'm sorry, 7210 is covered.
[AGENT][NEUTRAL] Uh, surgical removal, erupted tooth requiring evaluation that is covered under their oral surgery benefit.
[AGENT][NEUTRAL] Uh, which pays at 40% of usual and customary.
[CUSTOMER][NEUTRAL] And are these out of network benefits?
[AGENT][NEUTRAL] Uh, it's not a contracted policy, um.
[AGENT][NEUTRAL] It just it pays according to the schedule.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] So, and is that the schedule that you like I tell you the code and you tell me how much or?
[AGENT][NEUTRAL] Well, it's the 40% of the usual and customary, and that is determined by zip code.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, so it's usually customary, not, not an actual like your fee schedule.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So 7 to 10 is 40% and then 7240.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 7240.
[AGENT][NEUTRAL] 72,240 is also paid at um.
[AGENT][NEUTRAL] 40%.
[CUSTOMER][NEUTRAL] Alright, 7 to 50.
[AGENT][NEUTRAL] 7250 also paid at 40%.
[AGENT][NEUTRAL] And please be advised verifying benefits does not guarantee payment. I'm sorry, 72.
[CUSTOMER][NEUTRAL] 7251.
[CUSTOMER][NEUTRAL] 51.
[AGENT][NEUTRAL] 51 I do not show.
[AGENT][NEUTRAL] Uh, a part of their fee covers fee schedule.
[CUSTOMER][NEUTRAL] OK, and then 7260?
[AGENT][NEUTRAL] 7260 is a covered procedure at 40%.
[CUSTOMER][NEUTRAL] 7261.
[AGENT][NEUTRAL] 7261 also is covered.
[CUSTOMER][NEUTRAL] 30%.
[AGENT][NEUTRAL] At 40%, I'm sorry.
[CUSTOMER][NEUTRAL] That's OK. 9222.
[AGENT][NEUTRAL] Uh, let me just go back through here just to make sure I do not show, you said 9222?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK. I do not show 9222 as a covered procedure.
[CUSTOMER][NEUTRAL] 923 9.
[AGENT][NEUTRAL] I do not show 9239 as a covered procedure.
[AGENT][NEUTRAL] Let me just make sure it is not covered.
[CUSTOMER][NEUTRAL] And then 9230.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] 9230.
[AGENT][NEUTRAL] 0, um, 9230 is covered.
[AGENT][NEUTRAL] Uh, let me see the percentage.
[AGENT][NEUTRAL] That is covered under their major expenses, um, and which pays up to 40% will pay a 40% of the UCR.
[CUSTOMER][NEUTRAL] All right, and then 0140.
[AGENT][NEUTRAL] 0140 is covered.
[AGENT][NEUTRAL] Uh, that is covered under their basic benefits, basic expenses paid at 80% of UCR.
[CUSTOMER][NEUTRAL] Are there any guidelines, uh, frequency?
[AGENT][NEUTRAL] Uh, for 0, for that procedure?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, so it shows, let me go back here.
[AGENT][NEUTRAL] 40
[AGENT][NEUTRAL] Mm. So it says limited to two evaluation procedures in any combination of 0120,014001500160 and 0180 in a 12 month period.
[CUSTOMER][NEUTRAL] All right, and 0330.
[AGENT][NEUTRAL] Uh, let's see, that is also covered, let's see, that is covered under preventative at 100%.
[AGENT][NEUTRAL] And let me check that limitation on there.
[AGENT][NEUTRAL] And that is uh limited to one X-ray.
[AGENT][NEUTRAL] Procedure uh in a 5-year period, and that is in conjunction with 0.
[AGENT][NEUTRAL] 2100277 yeah 0210 and 0277.
[CUSTOMER][NEUTRAL] And 0367.
[AGENT][NEUTRAL] I do not show 0367 as a cover procedure.
[CUSTOMER][NEUTRAL] And is there a maximum deductible?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] So the calendar year maximum for this policy is 1500. There is a calendar year deductible that does not apply to preventative expenses.
[CUSTOMER][NEUTRAL] And can you tell me if it's remaining of the maxim deductible.
[AGENT][NEUTRAL] And let me check that.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, I show that [PII] has.
[AGENT][NEUTRAL] Um, the full $1500 available and she has not met her $50 deductible at this time.
[CUSTOMER][NEUTRAL] Are there any waiting periods?
[AGENT][NEUTRAL] Let me make sure.
[AGENT][NEUTRAL] Wait
[AGENT][NEUTRAL] So there is for major endodontic, periodontic, uh, posthodontic, and oral surgery, there is a 12-month waiting period.
[CUSTOMER][NEUTRAL] And what's the effective date?
[AGENT][NEUTRAL] I show this policy has been effective since [PII].
[CUSTOMER][NEUTRAL] So it will end.
[AGENT][NEUTRAL] Let me check one more.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] OK. And is there anything else I can help you with?
[CUSTOMER][NEUTRAL] Um, is the patient eligible for a 0140 or 0330?
[AGENT][NEUTRAL] Um, so 0130 is not covered as far as the 0140.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Let me make sure let's see 00140.
[AGENT][NEUTRAL] OK, so, uh, the 0140 is covered under the basic and is uh available.
[CUSTOMER][NEUTRAL] Alright, and then what about the 0330?
[AGENT][NEUTRAL] There are
[CUSTOMER][NEUTRAL] The panoramic.
[AGENT][NEUTRAL] OK, 0330 is a uh it can be um yes it's available.
[CUSTOMER][NEUTRAL] Alright, and if we're out of network, do you pay us directly or does the check go to the patient?
[AGENT][NEUTRAL] So the policy is not contracted, we always pay the provider if the provider submits the claim.
[CUSTOMER][NEUTRAL] OK, great, and where do I mail claims?
[AGENT][NEUTRAL] Claims are mailed to [PII].
[AGENT][NEUTRAL] 950.
[AGENT][NEUTRAL] That's [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And your payer ID?
[AGENT][NEUTRAL] Payer ID is 60801.
[CUSTOMER][NEUTRAL] And is there any way to get a copy of the fee schedule?
[AGENT][POSITIVE] Yes, ma'am, there is. Let me get that pulled up for you.
[AGENT][NEUTRAL] OK, and am I sending that to your attention, [PII]?
[CUSTOMER][POSITIVE] Yeah, that would be great.
[AGENT][NEUTRAL] OK, and what is the fax number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, it's on its way. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] I think that's it and what was your name?
[AGENT][NEUTRAL] My name is [PII]
[CUSTOMER][POSITIVE] All right, thank you so much hope you have a good day.
[AGENT][POSITIVE] You're welcome. You have a wonderful day yourself and thank you for calling APL.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[AGENT][NEUTRAL] Bye bye.