AccountId: 011433970860
ContactId: 9cab101e-62a5-4784-a790-7f2479f21c6e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 860950 ms
Total Talk Time (AGENT): 246221 ms
Total Talk Time (CUSTOMER): 249882 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/27/9cab101e-62a5-4784-a790-7f2479f21c6e_20250527T17:02_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is. How may I help you?
[CUSTOMER][NEUTRAL] Hello, [PII]. This is [PII], calling on behalf of the provider's office. And I'm looking for dental benefits for one member today. So can you please assist me with that?
[AGENT][NEUTRAL] Yes, [PII], I can help you with benefits. May I please get your call back number and the provider's office you're calling from?
[CUSTOMER][NEUTRAL] The callback number is [PII] and it's a direct line. And the office name, that is Rockcliffe Oral and Facial Surgery.
[AGENT][POSITIVE] OK, thank you so much. And then what is the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] I'm gonna get you the member ID first. It is 262-4400. This is the member ID and the patient's name, that is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] OK, let me pull up her policy real quick.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, I do show that [PII] does have an active policy with us. The effective date of the policy is [PII].
[AGENT][NEUTRAL] And if you can give me your fax number, I'll send you a fax back with her benefit program and fee schedule.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Unfortunately, I don't have fax access story, so that's why I have to.
[CUSTOMER][NEUTRAL] Make this call. So, the effective date [PII]. And I do have a lot of questions about this members plans, the group name, group number, annual max deductibles.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK alright let me give you the um group name first is.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Friday services.
[CUSTOMER][NEUTRAL] I'm sorry, that's Friday, F R I D A Y?
[AGENT][NEUTRAL] Yes, sir.
[AGENT][NEUTRAL] And the group number is 70099.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] And let me look up her benefits real quick. It's gonna be just a moment so the computer can pull them in.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Just just one minute.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, looking at this policy, she has uh.
[AGENT][NEUTRAL] Calendar year and this is just to verify her benefits. It's not a guarantee of payment. She has a calendar year maximum of $750.
[AGENT][NEUTRAL] She has a $50 deductible.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And she does not have a waiting period.
[CUSTOMER][POSITIVE] No waiting period. Thank you. And the missing tooth cloth, do you have a missing tooth cloth?
[AGENT][NEGATIVE] Yes sir, there is a missing tooth cloth.
[CUSTOMER][NEUTRAL] And in plants, they are not downgraded.
[AGENT][NEUTRAL] Implants are not covered on the policy.
[CUSTOMER][NEUTRAL] OK. Thank you. And orthodontics, uh, is that a covered service?
[AGENT][NEUTRAL] No, sir. Orthodontic treatment is also not covered. She only has preventative and basic.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh, preventative and basic. OK, got it. Also not covered. So from their annual maximum deductibles, this member has used anything from it?
[AGENT][NEUTRAL] No, sir, she still has $150 left and she also has her deductible of $50 left to pay.
[CUSTOMER][NEUTRAL] No family deductible.
[AGENT][NEUTRAL] There is a family deductible, but she's the only person on the policy. The family deductible is $150.
[CUSTOMER][NEUTRAL] Thank you. And the coinsurances for preventative, basic, and major services they are?
[AGENT][NEUTRAL] Only for preventative and basic.
[CUSTOMER][NEUTRAL] Basic, yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, preventative services, they are covered.
[AGENT][NEUTRAL] No, the, um,
[AGENT][NEUTRAL] Does not apply to preventative services for her deductible.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh no, no, no. I'm looking for the coinsurances the percentages they are covered.
[CUSTOMER][NEUTRAL] Preventative services and basic.
[AGENT][NEUTRAL] There is no coinsurance.
[AGENT][NEUTRAL] Right, it's just preventative and basic on.
[CUSTOMER][NEUTRAL] No coinsurance.
[CUSTOMER][NEUTRAL] They're just covered, right? No coinsurances.
[AGENT][NEUTRAL] Right, it's just um covered the fee schedule is UCR.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK. The schedule be UCR and I do have some procedure codes here with me to check. So were you able to assist me with the codes?
[AGENT][NEUTRAL] Sir, let me get this policy pulled up to where I can.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, what is the first procedure code?
[CUSTOMER][NEUTRAL] It is 0140.
[AGENT][NEUTRAL] 0140.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me look.
[AGENT][NEUTRAL] That's a non-covered service.
[AGENT][NEUTRAL] It's not all of that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] On the plan
[CUSTOMER][NEUTRAL] Uh, OK.
[CUSTOMER][NEUTRAL] 0160
[AGENT][NEGATIVE] And that is not also not on plan.
[CUSTOMER][NEUTRAL] 9310
[AGENT][NEGATIVE] That is also not on the plan.
[CUSTOMER][NEUTRAL] 0330, which is the panoramic X-ray.
[AGENT][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] And that was 00130?
[CUSTOMER][NEUTRAL] 0330.
[AGENT][NEUTRAL] I'm looking.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That is um.
[AGENT][NEUTRAL] 80% of the allowable UCR.
[CUSTOMER][NEUTRAL] OK. And the next code is [PII] is not covered.
[AGENT][NEUTRAL] No sir, that's not on the.
[AGENT][NEUTRAL] Policy either.
[CUSTOMER][NEUTRAL] Plan, OK. What about simple extraction and surgical extractions? Are they covered service under this plan?
[AGENT][NEUTRAL] Uh, what is the code?
[CUSTOMER][NEUTRAL] For simple extraction, it is 7140.
[AGENT][NEUTRAL] Yes, that's considered by.
[AGENT][NEUTRAL] Which is 80% of the allowable.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, surgical extraction, 7210.
[AGENT][NEUTRAL] I'm looking for you, sir.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, that is not covered under the policy.
[CUSTOMER][NEUTRAL] And impacted tooth removal of impacted tooth 7.
[CUSTOMER][NEUTRAL] 220
[AGENT][NEUTRAL] Let me check.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No sir, that's not on the policy either.
[CUSTOMER][NEUTRAL] OK. And what about this procedure code 725 and I believe that one is not recovered. So 7251.
[AGENT][NEUTRAL] 251.
[AGENT][NEUTRAL] No, sir, that's not on the policy.
[AGENT][NEUTRAL] Either.
[CUSTOMER][NEUTRAL] And anesthesia general anesthesia 9223.
[AGENT][NEUTRAL] No, that's not on the policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] Not covered. OK. I believe the rest of the procedures are also not good plans, not good. What about this procedure, 72.
[CUSTOMER][NEUTRAL] I'm sorry, 7321 also not covered.
[AGENT][NEUTRAL] Right, unless it's basic or basic restorative, it is not covered under the plan.
[CUSTOMER][NEUTRAL] OK. Got it. And do you have any histories for the panoramic X-ray 0330?
[AGENT][NEUTRAL] Let me check real quick.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, sir. That has not been used yet.
[CUSTOMER][POSITIVE] OK. Got it. And I'm really sorry. Can I please have your name again?
[AGENT][NEUTRAL] My name is [PII], it's [PII]
[CUSTOMER][NEUTRAL] Got it. All right, got it. And [PII], before I let you go, can you please help me with the claims mailing address, the payer ID, and the call reference number?
[AGENT][NEUTRAL] Yes sir, um, the claims mailing address is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK, hold on. Ok [PII]. Uh-huh.
[AGENT][NEUTRAL] And the state is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that uh zip code is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] And you asked for one more thing, what was that sir?
[CUSTOMER][NEUTRAL] The payer ID?
[AGENT][NEUTRAL] Payer ID is 60801.
[CUSTOMER][NEUTRAL] One and the call reference number, totally?
[AGENT][NEUTRAL] That's going to be my name and today's date.
[CUSTOMER][POSITIVE] Got it. OK, got it. Thank you. So sorry, that would be it. So thank you so much for your assistance. Bye for now. Take care and have a nice day ahead.
[AGENT][POSITIVE] You too, [PII]. Thank you for calling APL. You have a nice day too you take care.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Bye-bye, sir.