AccountId: 011433970860
ContactId: 85d10fea-7376-49e4-831a-bcd32cd9db7f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 557520 ms
Total Talk Time (AGENT): 267478 ms
Total Talk Time (CUSTOMER): 201714 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/15/85d10fea-7376-49e4-831a-bcd32cd9db7f_20250115T15:09_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Yes, um, I was calling, um, I had some, uh, went to the dentist a couple of months ago and I was there for cleaning and they took X-rays and um they said that I needed a deep cleaning, me and my wife, and they uh sent you guys an email supposedly or somehow reached out to you guys telling we need a deep cleaning and.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] They said they were gonna call us back. They sent us home, so they're gonna call us back when they got back in touch with you guys to see what you guys wanted to do, and they never called us back, but a couple weeks or a month later we got a bill in the mail of $300 and some odd dollars. I was wanting to know if uh if it if it didn't cover the, the um X-ray or what, what happened in that situation?
[AGENT][NEUTRAL] Yeah, I can definitely take a look at that for you today. Um, do you mind, sir, if I get your policy number?
[CUSTOMER][NEGATIVE] Oh God, I don't even know it. Um, how do I look for that?
[AGENT][NEUTRAL] No, that's OK. I can search for a policy with your social if you'd like.
[CUSTOMER][NEUTRAL] OK, that's fine, um, [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Perfect, give me one second to get that searched for, and your first and last name, sir?
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] [PII], could you please verify for me your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect, thank you, thank you. And do you mind if I snag a really good callback number for you real fast?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]. And I'm just gonna have you verify for me your mailing address real quick.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and then I think the last thing is the.
[AGENT][NEUTRAL] The email on file if you can.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect, thank you.
[AGENT][NEUTRAL] All right, and it looks like, were you there?
[AGENT][NEUTRAL] Hm, from in September, end of September?
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Yeah, it was somewhere, so September October somewhere around that area.
[AGENT][NEUTRAL] OK, perfect. So we did get a claim in it looks like every charge we received, hold on, let me actually open up the claim, um, it does look like we had benefits payable, we paid $309.40 to your provider for this claim.
[CUSTOMER][NEUTRAL] You guys paid that much to towards the claim?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] So how much, so how much was the total bill?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] If it was, so I don't have the original claim on file but.
[AGENT][NEUTRAL] If these were the charges, let me add them up for you 187, 161.
[AGENT][NEUTRAL] The original bill was.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I mean, I don't know, uh, at least $468.
[CUSTOMER][NEUTRAL] 468.
[AGENT][NEUTRAL] Mhm, um, but I'm only seeing 3 charges on here. I can't see the original bill, so I don't.
[AGENT][NEUTRAL] Want to.
[CUSTOMER][NEUTRAL] Yeah, that's fine. Uh, I'm no, I'm just trying to figure out what because me and my wife went at the same time, so I'm trying to figure out did they only charge us, and you said there's 3 charges, so I'm trying to figure out what was what was all 3.
[AGENT][NEUTRAL] You know what I mean? I
[AGENT][NEUTRAL] Oh yeah, I actually can look at that for you, but it looks like if it was $468 and we paid the $309.40 it would have left you uh left over with $158.60 and then if it was for both of you that might.
[CUSTOMER][NEUTRAL] OK, so that's why our.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Match.
[CUSTOMER][NEUTRAL] That's, that's why it's $300 some odd dollars.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] Here I'm just pulling up these dental codes.
[CUSTOMER][NEUTRAL] So the, the, so basically, so basically we're paying, we pay for.
[CUSTOMER][NEUTRAL] The, the, um, you guys didn't didn't pay the full amount for the X-rays?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] We pay off of the usual and customary rate, so what that is is that is like the average rate that's charged for your zip code area, um, but that does not mean that's what the provider is charging, but we pay a percent based off that rate that is that what they call it usual and customary, um, for your location.
[AGENT][NEUTRAL] And so we don't really have control of what the providers charge individually when they submit the claims um we just take a look at what the average rate is in.
[AGENT][NEUTRAL] In your zip code and we pay based off of that so preventative it's 100% of the usual and customary rate um your basic expenses are gonna be 80% of the usual and customary rate and then your major expenses are 40% of the usual customary rate.
[CUSTOMER][NEUTRAL] OK, um, do you know if they charge us for, uh, deep cleaning or was it, uh, or was that just the, um, X-ray charges?
[AGENT][NEUTRAL] So I'm seeing on here the panoramic film that would have been from your X-ray. I'm seeing, and I'm just looking up these codes because I don't know them all off the top of my head, um, a comprehensive oral evaluation and
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] 00274 and bite wings so that would be the other part of uh the it's like when they have you bite down and they take the pictures um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So that they charged you for those 3 things the bite wings, the panoramic film, and the comprehensive oral evaluation.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, that's what I wanted to know. um, I was kind of confused.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] And what they charge us for because they never called us back to.
[CUSTOMER][NEUTRAL] See if um.
[CUSTOMER][NEGATIVE] And, and, and they might have didn't call us back because I didn't know that you have to have this insurance for a year for the cover deep cleaning so that might be the reason why they didn't call us back. I don't know.
[AGENT][NEUTRAL] Yeah, there is that 12 month waiting period for the major expenses, um, and I don't know.
[AGENT][NEUTRAL] I mean, like I, if I knew the code, I could like look it up and tell you where it fell on it, um, but I don't know.
[AGENT][NEUTRAL] It's like
[AGENT][NEGATIVE] it, um, I unfortunately I don't know like what code the deep cleaning would fall under, um, and how that would work.
[AGENT][POSITIVE] Off the top of my head. I'm so sorry.
[CUSTOMER][NEUTRAL] Yeah, that's fine.
[CUSTOMER][NEUTRAL] No, that's fine.
[CUSTOMER][NEUTRAL] OK, just say if we go back to get a um.
[CUSTOMER][NEUTRAL] And cleaning since they didn't do it the first time.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] To another dentist, start all over again, basically, um.
[CUSTOMER][NEUTRAL] And they had to do X-rays again.
[CUSTOMER][NEUTRAL] Well we still have to be.
[CUSTOMER][NEUTRAL] We still have to pay the, uh,
[CUSTOMER][NEUTRAL] Same um would you guys cover the same amount and we have to be responsible for the rest?
[CUSTOMER][NEUTRAL] In that situation.
[AGENT][NEUTRAL] Um, so, unfortunately, your X-rays are only covered once every 5 years.
[CUSTOMER][NEUTRAL] 05 years, OK.
[AGENT][NEUTRAL] Yeah, the bite wings themselves, um, so the bite wings that were the preventative ones, they're covered once a year. Um, but your, your full mouth like the panoramic one they took is once every 5 years.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] As far as what coverage you have there or like the limitation on it.
[CUSTOMER][POSITIVE] OK, I got you.
[CUSTOMER][POSITIVE] Alright, that's all I need to know, thank you.
[AGENT][POSITIVE] Yeah, it's my pleasure. If you have any other questions, please reach out. We'd be so happy to help you out, OK?
[CUSTOMER][POSITIVE] OK, I will thank you.
[AGENT][POSITIVE] My pleasure. Thank you.
[CUSTOMER][NEUTRAL] Mm bye.
[AGENT][NEUTRAL] Bye bye