AccountId: 011433970860
ContactId: 9451e9fa-8f60-4071-a595-cb9dd2d81b52
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1039900 ms
Total Talk Time (AGENT): 423821 ms
Total Talk Time (CUSTOMER): 667708 ms
Interruptions: 43
Overall Sentiment: AGENT=0.5, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/10/9451e9fa-8f60-4071-a595-cb9dd2d81b52_20250110T15:10_UTC.wav
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[AGENT][POSITIVE] Hi, thank you so much for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] [PII], this is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hello. Oh.
[CUSTOMER][NEUTRAL] Oh, hi.
[CUSTOMER][POSITIVE] Hi, good morning, miss. Uh, my name is [PII]. I'm calling to check on a patient added you and benefits.
[AGENT][POSITIVE] Yeah, I'd love to help you with eligibility benefits, and I'm so sorry I didn't quite catch it, but what was your name?
[CUSTOMER][NEUTRAL] No problem. That would be [PII], yeah.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you, Ms. [PII]. And then what is the callback number for you?
[CUSTOMER][NEUTRAL] [PII] and then what is the call back number for you? Sure, uh, the callback number that would be [PII].
[AGENT][POSITIVE] Wonderful, thank you. And your member's policy number?
[CUSTOMER][NEUTRAL] Uh-huh. It is, um, 1234. There's 500 consecutive zeros and then 2476163.
[AGENT][NEUTRAL] So our policy numbers are actually just 6 to 8 digits. Um, would there be like another number on their card?
[CUSTOMER][NEUTRAL] So our policy numbers are actually the 6 to 8 digits.
[CUSTOMER][NEUTRAL] Uh, maybe, OK, let me try, let's just try with 2476163.
[AGENT][NEUTRAL] OK, yeah, that sounds like one of our numbers.
[CUSTOMER][NEUTRAL] OK, yeah, that's fine.
[CUSTOMER][POSITIVE] Yeah, thank you.
[AGENT][POSITIVE] My pleasure. And give me just a moment to get this pulled up for you.
[CUSTOMER][NEUTRAL] My brother, give me just a moment to get this hold on.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] And can you verify for me, pretty please, your patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] And can you verify for me for your patience.
[CUSTOMER][NEUTRAL] Sure. Uh, that will be [PII], [PII].
[AGENT][POSITIVE] Perfect, thank you. Your patient is current and active. It looks like her
[CUSTOMER][POSITIVE] Perfect thank you your patient is current and active. It looks like her.
[AGENT][NEUTRAL] Effective date is
[CUSTOMER][NEUTRAL] Effectively is.
[AGENT][NEUTRAL] I cannot talk today. [PII].
[CUSTOMER][NEUTRAL] I cannot
[AGENT][NEUTRAL] And then are you wanting me to send you a fax back of benefits?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Uh, it would be great if you can assist me real quick please over the phone.
[AGENT][NEUTRAL] OK, yeah, I do wanna let you know that I benefit information I give you over the phone it's just a verification of coverage and never guarantee payment.
[CUSTOMER][NEUTRAL] OK, yeah, I do wanna let you know that. I mean, send me some information.
[CUSTOMER][NEUTRAL] It's just the verification.
[CUSTOMER][POSITIVE] Mhm thank you. Sure, for dental, thank you so much, miss. Uh, well, would that mean say, could you please help me with the um the group name and the group number, please?
[AGENT][NEUTRAL] And what benefit information can I help you with today?
[AGENT][NEUTRAL] You betcha. Um, the group number is 70036.
[CUSTOMER][NEUTRAL] You bet you um the group number is 7.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the group name is Crown Services.
[CUSTOMER][NEUTRAL] And the group's name is Crown Services. OK.
[AGENT][NEUTRAL] Inc
[CUSTOMER][POSITIVE] I like C R O W N.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, thank you. Could you also help me with the annual maximum the use amount as was the deductibles, please?
[AGENT][NEUTRAL] OK, yeah, absolutely. Let me pull up their calendar year balance real quick for you. Um, it looks like their annual maximum is $500 per person with a $50 deductible. Um, deductibles do not apply to preventative.
[CUSTOMER][NEUTRAL] OK, yeah, absolutely, let me pull up their calendar your balance real quick.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It looks like there's maximum of $500 per person with a $50 deductible. Um, deductibles do not apply to prevented. Mhm.
[AGENT][NEUTRAL] And let me check their calendar year benefits.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um, your patient has not used anything for the [PII] calendar year yet.
[CUSTOMER][NEUTRAL] Um, your patient has not used anything for the [PII] calendar year. OK, uh, it's just $500 right? $500.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, thank you. And is there any family deductible, miss?
[AGENT][NEUTRAL] The family deductible is $150.
[CUSTOMER][NEUTRAL] The family deductible is $150. OK, and is there anything out of 50?
[AGENT][NEUTRAL] No, they haven't submitted any claims in the 1st 10 days of the calendar year.
[CUSTOMER][NEUTRAL] No, they haven't submitted any claims in the 1st 10. OK, thank you and uh is there any coordination of benefits?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] I don't think so, no.
[CUSTOMER][NEUTRAL] I don't think so. OK, no COP. Any waiting period or missing class?
[AGENT][NEUTRAL] Uh, this policy does have a missing tooth clause, yes. There is no waiting period. The policy only covers preventative and basic.
[CUSTOMER][NEUTRAL] Uh, the policy does have permission to cause yes, there is no waiting period. The policy.
[CUSTOMER][NEUTRAL] OK, thank you. And yes, could you also help me with the co-insurance for preventive basic and endo period or surgery?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, yeah, so the endopyio and oral surgery, those are all majors, so they're not gonna be on here. We cover 100% of allowable for preventative expenses and then 80% for radiographs basic and basic restorative.
[CUSTOMER][NEUTRAL] Ma. OK, yeah, so the endocario and oral surgeries, they're all majors, so they're not gonna be done here. We cover 100% of allowable for preventative expenses and then 80% for radio.
[CUSTOMER][NEUTRAL] OK. So, preventive and diagnostic 100 and then basic AD and major adjunctive endopper oral surgery are not covered, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Thank you. And uh orthodontics, is it a covered benefit?
[AGENT][NEUTRAL] What is it?
[CUSTOMER][NEUTRAL] What is it? OK, the next.
[AGENT][NEGATIVE] Orthodontics are not covered on this plan.
[CUSTOMER][NEUTRAL] Orthodontic
[CUSTOMER][NEUTRAL] OK, thank you. And uh also, yes, I have a few procedures code for preventative and basic, um,
[CUSTOMER][NEUTRAL] I will be needing the frequencies and the percentage base.
[AGENT][NEUTRAL] The frequencies and what else?
[CUSTOMER][NEUTRAL] The frequencies and what else? Yeah, just a frequency and the percentage.
[AGENT][NEUTRAL] The person's age?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Oh, OK, yeah, I can look that up for you.
[CUSTOMER][POSITIVE] Oh OK, yeah, I can. Thank you. Did you need them all at once or we'll go one by one for the code?
[AGENT][NEUTRAL] Can we go one by one if that's OK? I just have to search them individually.
[CUSTOMER][POSITIVE] Can we go one by one if that's no problem.
[CUSTOMER][POSITIVE] No problem, no problem, that's fine.
[CUSTOMER][NEUTRAL] OK. So, um, if you're ready.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so my first code is 0140.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] All right.
[AGENT][POSITIVE] So 0140 is, I'm so sorry.
[CUSTOMER][NEUTRAL] So 0140 is.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Alright, it is covered under basic and it shares a frequency with 120, 150, 160, and it's limited to two oral evaluation procedures in any combination for twelve-month period.
[CUSTOMER][NEUTRAL] Right,
[CUSTOMER][NEUTRAL] And it
[CUSTOMER][NEUTRAL] with 1201.
[CUSTOMER][NEUTRAL] OK, 2 and 12 months. And it does share with the 05060 and 20.
[CUSTOMER][POSITIVE] OK. Thank you. And uh for the 01500160, they are, I'm sure 100% covered, right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] At AD.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] 150 is listed under preventative and let me check 160.
[CUSTOMER][NEUTRAL] 150
[AGENT][NEUTRAL] 160 is covered under basic.
[CUSTOMER][NEUTRAL] Mhm. 160 is covered under basic. OK, 80%. Thank you. And 0180?
[AGENT][NEUTRAL] I am not showing that 0180 is a covered procedure.
[CUSTOMER][NEUTRAL] I am not
[CUSTOMER][NEUTRAL] OK, so is it not covered?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, thank you. And also the next code is 0220.
[AGENT][NEUTRAL] I have that covered under basic.
[CUSTOMER][NEUTRAL] I have
[CUSTOMER][NEUTRAL] Basic and no frequency?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Thank you. And uh under this specific code, is there any specific guidelines, how many number of films megaphone mod X-ray?
[AGENT][NEUTRAL] It doesn't have any limitation listed under that code. It just says.
[CUSTOMER][NEUTRAL] It doesn't have any limitation under that code. It just says.
[AGENT][NEUTRAL] Intraoral first, oh, I guess it says first film, so maybe just the first one.
[CUSTOMER][NEUTRAL] Intro
[CUSTOMER][NEUTRAL] First, oh, I guess it's the first film, so maybe just the first one. OK, thank you. Um, there's 230 which is the additional film and that's covered under basic as well. Mhm.
[AGENT][NEUTRAL] Um, there's 230, which is each additional film and that's covered under basic as well.
[CUSTOMER][POSITIVE] OK. Thank you very much. And uh for the bite wings, the 0274.
[AGENT][NEUTRAL] Um, those are covered under preventative.
[CUSTOMER][NEUTRAL] Um, those are covered under preventative. Mhm. And would that, uh, what's the frequency for that?
[AGENT][POSITIVE] Oh, I'm sorry.
[CUSTOMER][POSITIVE] It's no problem.
[AGENT][NEUTRAL] Um, bite wings are once every 12 month period.
[CUSTOMER][NEUTRAL] OK, 1 in 12 months. And for the panel, 0210 or 0330?
[AGENT][NEUTRAL] Um, 0210 is covered and it is going to be
[CUSTOMER][NEUTRAL] Um, 0210 is covered.
[CUSTOMER][NEUTRAL] Going
[AGENT][NEUTRAL] Once every 5 years and it does share a frequency with 277 and 330 for every 5-year period.
[CUSTOMER][NEUTRAL] Once every 5 years and it does share a frequency with 277 and 330 for every 5 year period. OK, and it's preventative, right?
[AGENT][NEUTRAL] Um, no, it's not. It's considered a radiograph. It's covered at 80%, yup.
[CUSTOMER][NEUTRAL] Um, no, it's not. Oh, basic. OK, thank you. And uh for the 0431, is it a covered benefit?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] No. OK. 11:10.
[AGENT][NEUTRAL] 11:10 is considered preventative and the limitation on it is once every 6 months.
[CUSTOMER][NEUTRAL] 11:10 is considered preventative and the limitation on it is once every.
[CUSTOMER][NEUTRAL] OK, and 2006.
[AGENT][NEGATIVE] That's not covered.
[CUSTOMER][NEUTRAL] That's OK. 1351.
[AGENT][NEUTRAL] Um, that's gonna be covered under preventative. It has 3 limitations. Give me one moment on them.
[CUSTOMER][NEUTRAL] Um, that's gonna be covered under preventative. It has 3 limitations. Give me one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Uh, maximum of one procedure every 36 months, limited to dependent children aged [PII] and under, and applications made to permanent molar teeth only.
[CUSTOMER][NEUTRAL] Uh, maximum of one procedure every 36 months limited to dependent children aged [PII] and under and applications made to.
[CUSTOMER][NEUTRAL] OK, per Moller, thank you. And 2140.
[AGENT][NEUTRAL] Alright, 2140 is covered under preventative. It has two limitations. Let me get those for you.
[CUSTOMER][NEUTRAL] Alright, 2140 is covered under preventative.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, replacing existing if only
[CUSTOMER][NEUTRAL] Replacing existing if only.
[AGENT][NEUTRAL] I'm so sorry. Replace existing only if in place for 24 months, and what was the other one?
[CUSTOMER][POSITIVE] I'm so sorry.
[CUSTOMER][NEUTRAL] Only
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] A maximum of 1 each tooth per 24 months.
[CUSTOMER][NEUTRAL] A maximum of 12 months. OK, 1 in 24 months, thank you, and uh 2391.
[AGENT][NEUTRAL] 2391 is covered under basic restorative and it has the same um limitations as the last one.
[CUSTOMER][NEUTRAL] 2391 is covered under basic restorative and it has the same um limitations as the last one. Uh-huh. On 24 months. Any downgrade on the basic restoration here?
[AGENT][NEUTRAL] We don't downgrade.
[CUSTOMER][NEUTRAL] OK, no downgrade. OK. And uh also, um, I just want to know because some of the codes, uh, the 2950 and 2954, is it considered basic or major?
[AGENT][NEUTRAL] Um, I don't show 2950 is covered at all, and then what was the other 1, 2954?
[CUSTOMER][NEUTRAL] Um, I don't show 2950 is covered at all and then the other 12 yes.
[AGENT][NEUTRAL] And I don't show that one as a covered expenses as well.
[CUSTOMER][NEUTRAL] And I don't
[CUSTOMER][NEUTRAL] OK, thank you. Uh-huh. And uh 7140?
[AGENT][NEUTRAL] Hold on 1 2nd.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] 7140 is covered under basic and it has one limitation stating maximum one time per tooth.
[CUSTOMER][NEUTRAL] Uh, 7140 is covered under basic and it has one limitation stating maximum one time for two. OK. One in lifetime. Thank you. All right. And uh for Borncroft in a blue card, is it, uh, they considered a basic or major? I'm not sure, the 7953 and 9944.
[AGENT][NEUTRAL] I'm sorry, 7953 you said?
[CUSTOMER][NEUTRAL] Yes, yes, yes. And 9944.
[AGENT][NEUTRAL] I'm not showing coverage for any of those.
[CUSTOMER][NEUTRAL] I'm not showing coverage for. Mhm, no problem. 7210?
[AGENT][NEUTRAL] No.
[CUSTOMER][POSITIVE] OK. No problem. Thank you very much. OK. And is there any history on preventive, just the last bit of service?
[AGENT][NEUTRAL] Let me look at their history.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Um, it looks like their last oral exam, X-rays, prophy and bite wings were done on [PII], and they had a comp periodontal evaluation as well, um, on [PII].
[CUSTOMER][NEUTRAL] Um, it looks like their last oral exam.
[CUSTOMER][NEUTRAL] He
[CUSTOMER][NEUTRAL] Or
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Comp periodontal evaluation as well. Mhm.
[CUSTOMER][NEUTRAL] OK, OK. Um.
[AGENT][NEUTRAL] Um, it looks like.
[AGENT][NEUTRAL] Yeah, I'm sorry, that was it, just those.
[CUSTOMER][NEUTRAL] Yeah, I'm sorry, that was it. OK, OK, but uh the period on the the, the 4041, 49, 10, and 4355, those are not covered, right?
[AGENT][NEUTRAL] I'm so sorry, you're gonna have to go one at a time. I have to look them up individually.
[CUSTOMER][POSITIVE] I'm so sorry.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][POSITIVE] No problem. OK.
[CUSTOMER][NEUTRAL] Uh, 1st 1 49 10.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, 435-5.
[AGENT][NEGATIVE] Also not covered.
[CUSTOMER][NEUTRAL] OK, OK, I think then that should be it if it's not covered. OK, great. And also miss, uh, for the pre-authorization, would that be suggested?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] We don't require pre-authorization.
[CUSTOMER][NEUTRAL] We don't
[CUSTOMER][NEUTRAL] OK, thank you. And uh could you also tell me with the fee schedule please? What would be the fee schedule here?
[AGENT][NEUTRAL] Um, we have our own fee schedule. It's included on the fax back.
[CUSTOMER][NEUTRAL] Um, we have our own sea schedules included on the fax back.
[CUSTOMER][NEUTRAL] Uh, um, just the general fee schedule, not that, uh, dollar amount, yeah.
[AGENT][NEUTRAL] Oh no, I'm sorry. My bad. This one goes through the Carrington PPO B schedule. Our other policies, we created our own B schedule we send out, but this one follows Carrington.
[CUSTOMER][NEUTRAL] Oh OK, OK.
[CUSTOMER][NEUTRAL] OK, and uh is the provider in that group with this plan?
[AGENT][NEUTRAL] If you guys are partnered with the Carrington PPO network, um, I guess you would know that I wouldn't, um, but they can get a discount but they don't have to be in network to get their benefits.
[CUSTOMER][NEUTRAL] If you guys are partnered with the Carrington CTO network.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Um, but
[CUSTOMER][NEUTRAL] They don't have to be in network to get their benefits. OK, OK. So these are the, the benefits that you have given me, these are all in the benefits, right?
[AGENT][NEUTRAL] They're all what benefits?
[CUSTOMER][NEUTRAL] For all what? Uh, for in network benefits.
[AGENT][NEUTRAL] We don't have like an in-network out network benefits. This partner, this policy like participates in the Carrington PPO network, which is like a giant dental network set up to give people discounts when they see a dental provider, um, kind of like multiplan is for medical care. Um, however, they can still receive their benefits no matter who they see as a provider.
[CUSTOMER][NEUTRAL] We don't have like an in out this policy like participate in the CTO which is like a giant set up a dental provider, um, kind of like plan for medical care. Oh, OK, OK, great, got you, thank you so much, miss. Alright, and, uh, lastly.
[AGENT][POSITIVE] Yeah, absolutely.
[CUSTOMER][NEUTRAL] Thank you. Uh, could you please help me with the claims mailing address and a payer ID please?
[AGENT][NEUTRAL] Yes, our payer ID is 60801, and then our claims address you would make it to APL claims or American Public Life, your choice.
[CUSTOMER][NEUTRAL] Yes, our
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, we are [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We're in [PII], [PII].
[CUSTOMER][NEUTRAL] We're in [PII], Mhm.
[AGENT][NEUTRAL] And our zip code here is [PII].
[CUSTOMER][NEUTRAL] And our zip code here is [PII] and I'm so sorry I did not um.
[CUSTOMER][NEUTRAL] Get the city.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Ok [PII], OK, and what's the state?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] No, yeah, it's it's a lot of thin ones.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] I was confused. OK, no problem. Thank you. Alright, great. Uh, well, it looks like it's perfect. Thank you so much, Miss. Thank you so much for assisting me with this patient. And could you also me with the call reference number, please? Thank you. Uh huh. OK. OK, great, thank you so much, [PII]. You have a wonderful rest of the day, OK? And you have a great weekend as well.
[AGENT][NEUTRAL] You betcha. The call reference number is just my name, [PII], and today's date.
[AGENT][POSITIVE] My pleasure, yes, you too, miss.
[AGENT][POSITIVE] Thank you so much.
[CUSTOMER][POSITIVE] Thank you. Uh huh bye bye.
[AGENT][NEUTRAL] Bye-bye.