AccountId: 011433970860
ContactId: 9ecae6cd-eb28-4088-ace4-dc756af225c5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 976159 ms
Total Talk Time (AGENT): 414582 ms
Total Talk Time (CUSTOMER): 315153 ms
Interruptions: 2
Overall Sentiment: AGENT=1.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/08/9ecae6cd-eb28-4088-ace4-dc756af225c5_20250108T22:25_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] from a dental provider office. I was just to see my patient came with a certain insurance and I wanna see if we're in network with y'all.
[AGENT][POSITIVE] OK, yeah, I'd love to take a look at that for you, Ms. [PII], and do you mind if I really quickly grab a good callback number?
[CUSTOMER][NEUTRAL] Yeah it's gonna be [PII].
[AGENT][POSITIVE] Thank you. I appreciate that. And your member's policy number?
[CUSTOMER][NEUTRAL] It's going to be 01997256.
[AGENT][POSITIVE] Perfect.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Perfect. Could you verify for me, please, your patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, so I'm gonna spell it out. So that first name is gonna be [PII] Last name is [PII]
[CUSTOMER][NEUTRAL] And then that date of birth is [PII].
[AGENT][POSITIVE] Perfect, thank you so much and
[AGENT][NEUTRAL] Let me take a look into this for you.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] All right, so this plan that they have does not have a network, um.
[AGENT][NEUTRAL] I can send you if you needed a fax back that will have the um schedule of covered dental services and procedures listed on it.
[CUSTOMER][NEUTRAL] So it's not, it doesn't have like a fee schedule at all it goes by?
[AGENT][NEUTRAL] Um, the fee schedules included on the fax back.
[CUSTOMER][NEUTRAL] OK, so patients here and we're trying to get our faxed in like checked in. Is there any way you can just kind of tell me over the phone real quick?
[AGENT][NEUTRAL] Yeah, I absolutely can um I will have to look up individual codes so like one by one,
[AGENT][NEUTRAL] If that is OK with you.
[CUSTOMER][NEUTRAL] Well, can you just tell me the fee says like if we're in network or the fee schedule to see to see if.
[AGENT][NEUTRAL] There's no, there's no network we we pay all of it ourselves so you just submit the claims to us and then we pay it based off of um the usual and customary rate.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so what's the subscriber's first name?
[AGENT][NEUTRAL] Yes, absolutely. The subscriber's first name is [PII], same last name, [PII]
[CUSTOMER][NEUTRAL] And then [PII]?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then the group number?
[AGENT][NEUTRAL] All right, I have the group number listed as.
[AGENT][NEUTRAL] 21965.
[CUSTOMER][NEUTRAL] OK, and then what is the group name?
[AGENT][NEUTRAL] Uh, the group name is Universal Trucking, JLE Industries.
[CUSTOMER][NEUTRAL] JLE, is that what you said?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] JLA.
[CUSTOMER][NEUTRAL] And then OK, so what is exactly, oh what's that birthday for him? sorry.
[AGENT][NEUTRAL] For the subscriber?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] I can't give that to you. I'm sorry.
[CUSTOMER][NEUTRAL] Oh, OK, let me ask, what's this, uh, [PII]'s birthday?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Sorry, thanks.
[CUSTOMER][NEUTRAL] Oh, you're OK. OK, so what's, what would this be under then?
[CUSTOMER][NEUTRAL] Like the insurance name.
[AGENT][NEUTRAL] Uh, it's American Public Life.
[CUSTOMER][NEUTRAL] American
[CUSTOMER][NEUTRAL] OK, and then so I have a couple uh it's just that's what the fee schedule is too I'm assuming.
[AGENT][POSITIVE] Um, yeah, I would be willing to bet so.
[CUSTOMER][NEUTRAL] OK, what's the claim number?
[AGENT][NEUTRAL] The claims mailing
[CUSTOMER][NEUTRAL] What's the claims mailing address?
[AGENT][NEUTRAL] Yep, it's [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, can you give me one second? I'm gonna get the patient checked in. I just wanted to make sure that we were in network and we could see her. Give me 2 seconds, OK?
[AGENT][POSITIVE] Yeah, take your time.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so what is that individual deductible?
[AGENT][NEUTRAL] Um, yes, and I do wanna let you know if I'm talking anything with dollar amounts, just that anything I give you is a verification of coverage and not a guarantee of payment. Um, the individual deductible is $50 a person and they have a deductible of $150 a family.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Has anything been met for uh my patient?
[AGENT][NEUTRAL] For the calendar year, let me take a peek at that.
[AGENT][NEUTRAL] I don't have anything for the [PII] calendar year yet.
[CUSTOMER][NEUTRAL] OK, and what's that individual mac?
[AGENT][NEUTRAL] The individual max is $1500 a person.
[CUSTOMER][NEUTRAL] OK, and nothing's been met on that either?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then is there any ortho coverage on this?
[AGENT][NEGATIVE] Um, no, they do not have ortho coverage.
[CUSTOMER][NEUTRAL] OK, so preventative is covered, basic covered, and majors covered?
[AGENT][NEUTRAL] Um, yes, so they do have coverage. All of their major expenses have a 12 month waiting period which it looks like they will not be eligible. Oh no, they should be eligible. They've had it since [PII]. Um, preventative is covered at 100% UCR, um, basic at 80% UCR, and major at 40% UCR.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then so crowns are covered, bridges are covered, endos covered.
[AGENT][NEUTRAL] Yes, I do have endo crowns and bridges.
[CUSTOMER][NEUTRAL] Uh, are is implants, uh, covered?
[AGENT][NEUTRAL] Um, do you have an individual code you'd like me to look at?
[CUSTOMER][NEUTRAL] Yeah, yeah, and Plants is 6010.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] I do not have anything for the code 6010.
[CUSTOMER][NEUTRAL] OK, and then dentures?
[AGENT][NEUTRAL] And then again I can look that one for you by the individual code if you'd like as well my friend.
[CUSTOMER][NEUTRAL] Oh sorry, yeah, um, so a 5110?
[AGENT][NEUTRAL] No, you're OK. I just don't know him.
[CUSTOMER][NEUTRAL] Yeah, and then
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Alright, I do have 5110 listed as a covered service under major expenses.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, and then oral surgery?
[AGENT][NEUTRAL] Um, oral surgery is covered, um, with the same coverage rate as major.
[CUSTOMER][NEUTRAL] OK, so you said preventative is 100, basic was uh 80, and then uh major was 40?
[AGENT][NEUTRAL] You betcha. And then I didn't say this, but the preventative procedures do not apply to their deductible.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, so for like um an exam which is a 0120, what's the frequency in that?
[AGENT][NEUTRAL] Um, yeah, you betcha. The 0120 is limited to two procedures in any combination, the 120, 140, 150, 160, 180 per 12 month period.
[CUSTOMER][NEUTRAL] OK, and then the cleanings is that one, it's a 1110 is that 2 per calendar year too?
[AGENT][NEUTRAL] 1110. OK, hold on, that one I'll have to scroll up for.
[CUSTOMER][NEUTRAL] It's just like a prov.
[AGENT][NEUTRAL] Alright, so that one has just one limitation and it is 1 procedure per 6 months.
[CUSTOMER][NEUTRAL] Actually
[CUSTOMER][NEUTRAL] One procedure for 6 months. OK, so it's gonna be 0270 for bite wings.
[AGENT][NEUTRAL] 0270.
[AGENT][NEUTRAL] Yes, and so that one we're limited to one bite wing X-ray procedure 0270272274 per 12 month period.
[CUSTOMER][NEUTRAL] OK, and then what about an FMX or a pano like a um 0210?
[CUSTOMER][NEUTRAL] Or a 0330?
[AGENT][NEUTRAL] You bet you the 021022 or the 277,330 is limited to one procedure per 5 year period.
[CUSTOMER][NEUTRAL] Uh, 60 months and then the panel which is a 0330, is it the same?
[AGENT][NEUTRAL] Yes, that one was included.
[CUSTOMER][NEUTRAL] Do they share frequency? OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So for fluoride, which is 1206, what's the frequency on that?
[AGENT][NEUTRAL] 1246.
[CUSTOMER][NEUTRAL] 1206 sorry 0 yeah sorry yeah sorry.
[AGENT][NEUTRAL] Did I hear that? 1206. OK, perfect. I was about to say did I hear that right?
[AGENT][NEUTRAL] 1206, right, I'm just gonna type the word fluoride, um, because I don't know if I'm messing up.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Or 1208.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I don't have that listed anywhere. Usually it'll say something about fluoride even for children under [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEGATIVE] But I don't see any fluoride being covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, what about like a perio maintenance of 4910? What's the frequency in that? And is that gonna be under preventative or basic?
[AGENT][POSITIVE] That's an excellent question. Let's look it up 4910.
[CUSTOMER][NEUTRAL] OK, yeah.
[AGENT][NEUTRAL] Um, I don't see any co oh, I do see coverage for that. I do see that's covered with the limitation of one procedure every 6 months, and it's listed under periodontics, so it's gonna be covered at that, I believe the 40%, yes.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So and then um for like a simple extraction, like a 7140, what is that under?
[AGENT][NEUTRAL] Uh, the 7140 falls under basic and it also has a limitation. Let me read that to you.
[AGENT][NEUTRAL] Um, uh, maximum one time per tooth that makes sense.
[CUSTOMER][NEUTRAL] OK, so what about, um, does this policy have a missing tooth cloth?
[AGENT][NEUTRAL] This policy does have a missing tooth clause.
[CUSTOMER][NEUTRAL] OK, what about a SRP a 4341? What's the frequency in that?
[AGENT][NEUTRAL] 4341.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Um, OK, let me find it for you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] It's a maximum of 1 each quadrant per 24 months, and it looks like it is covered under
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So how's that?
[AGENT][NEUTRAL] It's covered under periodontic expenses at 40%.
[CUSTOMER][NEUTRAL] OK, can both quads be done on the same day?
[AGENT][NEUTRAL] I believe they can, yes, um, it doesn't have a limitation around how many quads are done on the same day, just how many times each quad is done.
[CUSTOMER][NEUTRAL] OK, and then is a 4381 covered that's a resting.
[AGENT][NEUTRAL] The 4381 um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, I do have 4381 listed as a covered procedure also again under the periodontic expenses.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, is there any frequency in that? Hi, are you [PII]?
[AGENT][NEUTRAL] That one didn't have a limitation on it.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK, and then what about a 0431? Is this a covered benefit?
[AGENT][NEUTRAL] 0431.
[AGENT][NEUTRAL] I am not showing 0431 listed anywhere.
[CUSTOMER][NEUTRAL] OK, for crowns like a 27, 21, what's the frequency in that?
[AGENT][NEUTRAL] Uh, 2721. Hang tight, it has two limitations. It is covered under major AADD, um, one maximum of 1 per seven-year period and limited to patients [PII] and over.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Hold on, [PII], where you start filling this out and then I'll get your license and everything in just a second, OK? OK, um, OK, so my patient's not eligible for those.
[AGENT][NEUTRAL] Uh yes, I didn't really catch their age. No, I'm sorry.
[CUSTOMER][NEUTRAL] OK, so crowns, bridges.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Dentures, it's over how old? [PII], is that what you said?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, DD, yeah, patients over [PII].
[CUSTOMER][NEUTRAL] And then our
[CUSTOMER][NEUTRAL] OK, are crowns and bridges um downgraded?
[AGENT][NEUTRAL] We don't downgrade on any of it. I'm sorry.
[CUSTOMER][NEUTRAL] OK, no, that's, that's great, um, is predetermination mandatory?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And I just wanna confirm that they did have a waiting period but they fulfilled that.
[AGENT][NEUTRAL] Yes, they have been with us for, they'll be going on 4 years this March, and we only had a 12 month waiting period.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and then I just wanna make crowns are paid on um seat date.
[AGENT][NEGATIVE] We don't distinguish between prep or received, we just won't pay it twice.
[CUSTOMER][NEUTRAL] OK, um, can I go ahead and get that fax of this?
[AGENT][POSITIVE] Yeah, you betcha. No worries. Let me fill it out really, really fast.
[CUSTOMER][NEUTRAL] OK, and then
[CUSTOMER][NEUTRAL] Yeah, and can I get a reference number as well?
[AGENT][NEUTRAL] Yes, absolutely. The reference number is my name, [PII], first initial, last name, [PII], and then today's date.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] I'm just waiting for that dialog box to pop up for the fax. Give me one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And may I ask what a
[AGENT][NEUTRAL] Attention to do you want that attention to yourself today, ma'am?
[CUSTOMER][NEUTRAL] Yeah, you can just put [PII] that's fine.
[AGENT][POSITIVE] Perfect. [PII], or is there [PII] there as well or an [PII]?
[CUSTOMER][POSITIVE] Um, [PII] is fun.
[AGENT][POSITIVE] [PII], perfect. And what is the, the fax number for you, my friend?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's gonna be [PII], I mean sorry [PII].
[AGENT][POSITIVE] Perfect. And all right, I'm hitting send on that for you, Ms. [PII]. It should be coming through. I have it going to [PII].
[CUSTOMER][POSITIVE] Perfect, thank you.
[AGENT][POSITIVE] Hey, it's my pleasure. Thank you so much for giving us a call here at APL and I hope you have a fabulous day.
[CUSTOMER][POSITIVE] You too thanks bye bye.
[AGENT][POSITIVE] My pleasure bye bye.
[CUSTOMER][NEUTRAL] Yeah.