AccountId: 011433970860
ContactId: 9ffbf2fb-8713-45f7-9ede-47ab129bb80f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 665000 ms
Total Talk Time (AGENT): 256167 ms
Total Talk Time (CUSTOMER): 119020 ms
Interruptions: 0
Overall Sentiment: AGENT=0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/28/9ffbf2fb-8713-45f7-9ede-47ab129bb80f_20250528T12:11_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. I'm calling from Battlefield Family Dentistry. I was just reaching out, um, to try to verify a patient's dental policy.
[AGENT][POSITIVE] OK, I'm happy to check on benefits. Do we have their policy number?
[CUSTOMER][NEUTRAL] Um, so the policy number that they gave us was 02605910.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. And then what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] and his date of birth is [PII].
[AGENT][NEUTRAL] OK. Patient is active. It looks like their effective date on here is [PII].
[AGENT][POSITIVE] And then if you need us to, we can also send you a fax back with a breakdown of benefits or verbally give you whatever you need over the phone.
[CUSTOMER][NEUTRAL] OK, um, now I'm not familiar with this insurance policy. Could you tell us if he's in or out of network or?
[AGENT][NEUTRAL] So this particular policy doesn't require any sort of network for usage. It looks like it just pays off of UCR, um, and then the percentages, of course.
[CUSTOMER][NEUTRAL] OK, so we would have no way of knowing like what the UCR is for the services unless we do like a pre-authorization.
[AGENT][NEUTRAL] Yeah, it does follow the Carrington PPO network, but it's not required for usage. I don't know if that would help you guys.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alrighty and then what would be, um, could I get a a verbal breakdown of his benefits?
[AGENT][NEUTRAL] Yeah, so calendar maximum is going to be 1500.
[AGENT][NEUTRAL] The calendar year deductible is going to be 50 per covered up to $150 per family.
[AGENT][NEUTRAL] Uh, deductible does not apply to any sort of preventative services.
[AGENT][NEUTRAL] And then, uh, the patient has, it looks like preventative is covered at 100%.
[AGENT][NEUTRAL] FMX and basic expenses are covered at 80.
[AGENT][NEUTRAL] And then major covered at 40, that would include endoyio and oral surgery.
[AGENT][NEUTRAL] All major expenses do have a twelve-month waiting period that does include the endoperio and oral surgery.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] As far as frequencies go, cleanings are once every 6 months, exams 2 for 12.
[AGENT][NEUTRAL] White wings or once for 12 months.
[AGENT][NEUTRAL] FMX or once per 5 years, solar panels.
[AGENT][NEUTRAL] Crowns and bridges once every 7 years, and then partials and dentures once every 5.
[AGENT][NEUTRAL] Uh, policy does have a missing tooth clause, and it looks like orthodontic treatment is not covered, however.
[CUSTOMER][NEUTRAL] And can you tell me if there's an age limitation for fluoride and sealants?
[AGENT][NEUTRAL] There is I know let me see one moment.
[AGENT][NEUTRAL] Uh, fluoride.
[AGENT][NEUTRAL] All right, so it looks like Florida's gonna be limited to dependent children under the age of [PII].
[AGENT][NEUTRAL] And then feel it.
[AGENT][NEUTRAL] Um, is limited to dependent children under the age of [PII] also.
[CUSTOMER][NEUTRAL] And can you tell me if posterior composites are given an alternate benefit of amalgam?
[AGENT][NEUTRAL] I'm not even, I'm never, I've never been asked that before. Do you have a code for that or?
[CUSTOMER][NEUTRAL] Sure, um, post your composites, it's D2391 to D2394.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Are you just looking to see if there's downgrades on them?
[CUSTOMER][POSITIVE] Mhm yep, that's an alternate benefit.
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] Uh, looks like no downgrade. The only limitations I see is a replacement of an existing only if in place for 24 months.
[AGENT][NEUTRAL] And then it does have a maximum of 1 each tooth per 24 months.
[CUSTOMER][NEUTRAL] And could you tell me if the crowns have an a downgrade as well and I can give you that code.
[AGENT][POSITIVE] Yeah, absolutely, go ahead.
[CUSTOMER][NEUTRAL] D 2740.
[AGENT][NEGATIVE] No downgrade. It looks like limited to patients over the age of [PII], and there is a limitation of 1 per 7 year.
[CUSTOMER][NEUTRAL] And are they paid on prep or CD?
[AGENT][NEUTRAL] Either it doesn't matter.
[CUSTOMER][NEUTRAL] And is there any implant coverage on the policy?
[AGENT][NEUTRAL] I don't believe there is one second, let's see.
[AGENT][NEGATIVE] Uh, no, they are not covered.
[CUSTOMER][NEUTRAL] OK and then um may I have the claims address and payer ID?
[AGENT][NEUTRAL] Absolutely. Payer ID is 60801.
[AGENT][NEUTRAL] And the claims mailing address is gonna be [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] That's in [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] And then um I have a few procedure quotes. Could you just tell me if they were a covered benefit?
[AGENT][POSITIVE] Yeah, absolutely. Go ahead.
[CUSTOMER][NEUTRAL] Um, so the first one is the D0220, the PA.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] It looks like it is covered at 80%, no limitation.
[CUSTOMER][NEGATIVE] Um, the D 4355 full not the brightman.
[AGENT][NEUTRAL] Alright, so it looks like that is covered at 40% and
[AGENT][NEUTRAL] It is a maximum of 1 quadrant per 24 months.
[CUSTOMER][NEUTRAL] And then the procedure code D 4910 the period maintenance.
[AGENT][NEUTRAL] Um, looks like that is covered at 40%.
[AGENT][NEUTRAL] And it's a maximum of 1 procedure for 6 months.
[CUSTOMER][NEUTRAL] D 2950.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] So that is covered at 40%.
[AGENT][NEUTRAL] And it looks like a maximum of 1 procedure for 7 months.
[AGENT][NEUTRAL] And limited patients over the age of [PII].
[CUSTOMER][NEUTRAL] Um, the [PII].
[AGENT][NEGATIVE] I do not see [PII] listed on here, so it would not be covered.
[CUSTOMER][NEUTRAL] OK, and then one more, I'm so sorry I've got D [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEGATIVE] I don't see [PII] listed so it wouldn't be covered.
[CUSTOMER][NEUTRAL] Perfect and then what was your name? um just for our record?
[AGENT][NEUTRAL] My name
[AGENT][NEUTRAL] Yeah, no worries. My name is [PII], which is [PII] My last initial to my name is [PII], and that's the call reference with today's date.
[CUSTOMER][POSITIVE] All right, I appreciate all your help thank you so much.
[AGENT][POSITIVE] You're welcome. Have a great day.
[CUSTOMER][NEUTRAL] You too bye bye.