AccountId: 011433970860
ContactId: 7c8ed96c-3f55-4b7c-962c-e966aff98205
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 769500 ms
Total Talk Time (AGENT): 288822 ms
Total Talk Time (CUSTOMER): 137314 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/7c8ed96c-3f55-4b7c-962c-e966aff98205_20250213T15:30_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi and I'm trying to get the eligibility and full breakdown for a patient.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the eligibility and the breakdown. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's [PII] and then it's [PII].
[AGENT][POSITIVE] Thank you for that. And hold on one moment.
[AGENT][NEUTRAL] And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, it's um well I have her social is that OK?
[AGENT][NEUTRAL] Yes, that's fine.
[CUSTOMER][NEUTRAL] OK, it's [PII].
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] So I'm just waiting for the policies to pop populate here. Hold on one moment.
[AGENT][NEUTRAL] And what is the member's first and last name?
[CUSTOMER][NEUTRAL] It's [PII] and her date of birth is [PII].
[AGENT][NEUTRAL] Can you spell the last name for me, please?
[CUSTOMER][NEUTRAL] Yes, it's [PII]
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] So [PII] share. OK, here we go.
[AGENT][NEUTRAL] Because for some reason it didn't come up with, oh, I see. The social is different. Hold on one moment.
[AGENT][NEUTRAL] Alright, and I have the policy here and um thank you for verifying her date of birth and I'm showing the policy number is 124.
[AGENT][NEUTRAL] 651 9.
[CUSTOMER][NEUTRAL] OK, so her member ID number is going to be 1246519 correct?
[AGENT][POSITIVE] Mhm. Yes, that's correct.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Perfect thank you.
[AGENT][NEUTRAL] And that
[AGENT][NEUTRAL] You're welcome and all the information provided is a verification of benefits, not a guarantee of payment. And from my notes, I'm sorry, can you repeat your name for me, please, because I typed it and it didn't type.
[CUSTOMER][POSITIVE] Yeah, no worries. It's [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, and let me see what type of uh dental policy she has. Hold on one moment.
[CUSTOMER][POSITIVE] No worries.
[AGENT][NEUTRAL] And were you needing a copy of the fax back or you wanted to go over it over the phone?
[CUSTOMER][NEUTRAL] Um, could I go over the phone? Our fax is currently not working.
[AGENT][NEUTRAL] Sure, OK, it's coming up now. Hold on one moment.
[AGENT][NEUTRAL] So for the calendar year max, the policy will pay up to $1500 per cover insured.
[AGENT][NEUTRAL] There is a $50 deductible per insured up to $150 per family.
[AGENT][NEUTRAL] And the deductible does not apply to preventative services.
[AGENT][NEUTRAL] This policy has been active since [PII].
[AGENT][NEUTRAL] Preventative expenses are covered at 100% of UCI?
[AGENT][NEUTRAL] Radiograph and FMX basic and basic restorative expenses are all covered at 80% of UCR.
[AGENT][NEUTRAL] Major expenses, including endogenic, periodontic, proteodontic, and oral surgery are all at 40% of UCR.
[AGENT][NEUTRAL] With a 12-month waiting period, but that's passed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Profies and cleanings at once every 6 months?
[AGENT][NEUTRAL] Exams are 2 for 12 month period.
[AGENT][NEUTRAL] Full mouth X-rays and panels are once every 5 years.
[AGENT][NEUTRAL] Crowns and bridges are once every 7 years per tooth.
[CUSTOMER][NEUTRAL] And are they paid on CD or prep date?
[AGENT][NEUTRAL] Um, either or there's no specification.
[CUSTOMER][NEUTRAL] And is that the same for dentures?
[AGENT][NEUTRAL] Partials and dentures are once every 5 years.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] This
[CUSTOMER][NEUTRAL] Is there implant coverage?
[AGENT][NEUTRAL] There's um implant placement, removal and all related services are not covered.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEGATIVE] There is a missing tooth cloth.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Orthodontic treatment is not covered?
[AGENT][NEUTRAL] TMJ services are not covered?
[AGENT][NEUTRAL] Um, for our claims information, our payer ID is 60801.
[CUSTOMER][NEUTRAL] OK and then are we in network with this patients plan?
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] So there's no um network for this policy.
[CUSTOMER][NEUTRAL] OK, is there a fee schedule?
[AGENT][NEUTRAL] It uses um usual and customary charges.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is night shift covered under this plan 90,230?
[AGENT][NEUTRAL] Um, did you need the claim's mailing address or the fax number or the payer ID is OK?
[CUSTOMER][NEUTRAL] Uh, the payer ID number is OK.
[AGENT][NEUTRAL] OK, and what was the code you asked for?
[CUSTOMER][NEUTRAL] Um, 9230 for nitrous.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] Um, that's covered under major at 40%.
[CUSTOMER][NEUTRAL] Is there a frequency?
[AGENT][NEUTRAL] No.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Let me see, is there, um, are there downgrades on fillings?
[AGENT][NEUTRAL] Um, there's no downgrades.
[CUSTOMER][NEUTRAL] And then um let me see, could I get the frequency for SRP 4341?
[AGENT][NEUTRAL] 4341.
[CUSTOMER][NEUTRAL] And can all 4 quads be done same day?
[AGENT][NEUTRAL] Hold on one moment, 4341.
[AGENT][NEUTRAL] OK, that's under major at 40% and maximum of 1 each quadrant per 24 months.
[CUSTOMER][NEUTRAL] OK perfect and then can all 4 quads be done same day or no?
[AGENT][NEUTRAL] Um, there's no specification.
[CUSTOMER][NEUTRAL] No, OK, perfect. And then for 4910 for payroll maintenance, could I get the frequency for that?
[AGENT][NEUTRAL] Hold on one moment, 49.
[AGENT][NEUTRAL] Um, one procedure per 6 months.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] And then um is there any history under this plan?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Let me see, hold on one moment.
[AGENT][NEUTRAL] Um, yes, there is, we've, um, processed a few claims for, um, her. Do you have any particular code you're looking for?
[CUSTOMER][NEUTRAL] Um, what is her recent? Has it been like exams, pro fees, panel, or FMX?
[AGENT][NEUTRAL] Um, hold on one moment. I have to go through the claims. Let me see.
[AGENT][NEUTRAL] The most recent claim process is for data service [PII].
[AGENT][NEUTRAL] And hold on one moment.
[AGENT][NEUTRAL] But it was for a non-covered charge, um.
[AGENT][POSITIVE] It's easier if you have the code, I can just put the code in and it'll search each claim rather than me clicking through all the claims we've processed.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] 20,210.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, 033002740120 and 11,110.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] 00330, um, last day of service is uh [PII].
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the next one was 0274.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] There's no history on file for that um code?
[AGENT][NEUTRAL] There's no history on file for 00120?
[AGENT][NEUTRAL] Or 01110.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK perfect thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] OK and then is there a group name or group number under this plan?
[AGENT][NEUTRAL] Yes, um, the group number is 15197.
[AGENT][NEUTRAL] And the group name is Universal Trucking.
[AGENT][NEUTRAL] DJ, so D like dog, N like Nancy, J like juice.
[AGENT][NEUTRAL] Intermodal, I N T E R, M as in Mary, O D as in dog, A L.
[CUSTOMER][NEUTRAL] OK perfect thank you. Other than that, could I get your reference number and that should be it.
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name and today's date. The first initial to my last name is [PII].
[CUSTOMER][POSITIVE] OK perfect thank you so much for your help today.
[AGENT][POSITIVE] You're welcome, [PII]. Was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] Um, no, that should be it. Thank you.
[AGENT][POSITIVE] Alright, well, thanks for calling API. You're welcome. Bye bye.