AccountId: 011433970860
ContactId: a5138bfe-0c90-48a6-bb32-b6ddbc6043d3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 773520 ms
Total Talk Time (AGENT): 185191 ms
Total Talk Time (CUSTOMER): 294904 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/15/a5138bfe-0c90-48a6-bb32-b6ddbc6043d3_20250415T20:19_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII] calling on behalf of the dental office to check on the eligibility and benefits of a patient on a recorded call. Would you please help me with that?
[AGENT][POSITIVE] Yes, [PII], I can help you with benefits and eligibility. Do you have a good callback number?
[CUSTOMER][NEUTRAL] Sure. It's [PII]. It's a direct line.
[AGENT][NEUTRAL] OK, thank you. Do you have the policy number of the patient?
[CUSTOMER][NEUTRAL] Policy number ID is 02569305.
[AGENT][NEUTRAL] And patient name and date of birth?
[CUSTOMER][NEUTRAL] Uh, [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] OK, it looks like he's effective [PII]. Policy is currently active.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And this is not a guarantee of payment, it's a basic outline of the policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, I can send a fax back that has all of the benefits outlined, um, or we can go over some on the phone.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right, yes, we can go the ones that we can go over the phone, the ones that would not be available in the fax.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, honey.
[CUSTOMER][NEUTRAL] All right. um, first off, may I know if this is a, is this a calendar year plan, [PII]?
[AGENT][NEUTRAL] Um, let's see, this is.
[AGENT][NEUTRAL] Pulling it up. Give me one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, it is.
[CUSTOMER][NEUTRAL] All right, and the coordination of benefit is standard?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And is the provider in network or does the provider have network?
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Um, they can see any provider they like.
[CUSTOMER][NEUTRAL] All right, no network. Got it. So, uh, may I please have the, um, annual max details?
[AGENT][NEUTRAL] Um, yes, um, and again, not a guarantee of payment, basic outline of the policy. Annual maximum is 1500 per covered person.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, deductibles.
[AGENT][NEUTRAL] A deductible is $50. That's gonna apply to radiographs, FMX, basic expenses, and major expenses.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it. Any family deductible?
[AGENT][NEUTRAL] Uh, family is
[AGENT][NEUTRAL] That's just, it stays $50 per covered insured.
[CUSTOMER][NEUTRAL] OK, no family deductible. Has the patient used or me anything?
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Give me one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, looks like he's used 49,820.
[CUSTOMER][NEUTRAL] Got it. 498 20, and the deductible, has the patient met the deductible?
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Uh, let's see, has not met the deductible.
[CUSTOMER][NEUTRAL] Got it. May I know if there's any auto coverage for this patient?
[AGENT][NEGATIVE] Um, no, no orthodontic coverage.
[CUSTOMER][NEUTRAL] OK. Is there any missing class or waiting period?
[AGENT][NEUTRAL] Yes, there is a missing two clause waiting period for
[AGENT][NEUTRAL] Basic restorative major endo imperio and prosedonic is 12 months.
[CUSTOMER][NEUTRAL] All right. All right. May I please have the coinsurance breakdown?
[AGENT][NEUTRAL] Preventative pays 100%, radiographs, FMX, basic.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That pays 80% and then basic restorative major endopperio prosthodontic pays 40%.
[CUSTOMER][NEUTRAL] Basic restorative phase 80 major endopyal prothodontics. Got it. And uh oral surgeries?
[AGENT][NEUTRAL] Um, 7140 pays 80%, yes.
[CUSTOMER][NEUTRAL] Is it under the basic?
[CUSTOMER][NEUTRAL] 7240
[AGENT][NEUTRAL] 7140.
[CUSTOMER][NEUTRAL] 7240.
[AGENT][NEUTRAL] Uh, I don't see that code listed.
[CUSTOMER][NEUTRAL] Oh, OK. 7240. Got it. And then, um, to check here, for the filling and crown, are there any downgrades?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] No downgrades in the plan. Crown is paid on the seat date or prep date.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Prep date, and the frequency would be?
[AGENT][NEUTRAL] For what?
[CUSTOMER][NEUTRAL] The the crown, the crown, the replacement part for the crown.
[AGENT][NEUTRAL] Oh, let me see.
[AGENT][NEUTRAL] Uh, 5 year.
[CUSTOMER][NEUTRAL] 5 years. It's, it'll be the same with the denture bridge?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] The replacement class.
[CUSTOMER][NEUTRAL] Got it. And uh so the ones that are covered at 40% has 12 month waiting period, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] All right, got it. May I please have the frequencies only for preventive services?
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Uh evaluations are 2 in any 12 month period.
[AGENT][NEUTRAL] Cleaning one for 6 months.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What else?
[CUSTOMER][NEUTRAL] Uh, for the bite weight?
[AGENT][NEUTRAL] Uh, by wing is one bite wing for 12 months.
[CUSTOMER][NEUTRAL] Got it. For FMX?
[CUSTOMER][NEUTRAL] FMex is under the basic, right? 80%.
[AGENT][NEUTRAL] Yes, it is by wing, um, that is.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I see.
[AGENT][NEUTRAL] 1 for 5 year period.
[CUSTOMER][NEUTRAL] OK. Does it share with the panel?
[AGENT][NEUTRAL] I've got the code [PII].
[CUSTOMER][NEUTRAL] All right, [PII]. Great, thank you. And then fluoride insulin with the age limit. Um, may I know uh if the patient is eligible, [PII]?
[AGENT][NEUTRAL] No, they're not. [PII].
[CUSTOMER][NEUTRAL] Alright, patient is not eligible for fluoride and [PII]. Got it. And I just have a few more questions actually. We're almost done for the scaling planning, all quads can be done on the same day.
[AGENT][NEUTRAL] Um, yes.
[CUSTOMER][NEUTRAL] All right, and the frequency here would be?
[AGENT][NEUTRAL] Um, do you have the
[CUSTOMER][NEUTRAL] Uh, I'll just provide you with the code. It's [PII].
[AGENT][NEUTRAL] Acts of one quadrant for 24 months.
[CUSTOMER][NEUTRAL] Got it. And then 4 4355?
[AGENT][NEUTRAL] Uh, same.
[CUSTOMER][NEUTRAL] No same. 4381.
[CUSTOMER][NEUTRAL] Is this covered?
[AGENT][NEUTRAL] Uh, it doesn't, uh, list any frequency.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Oh, no frequency? Got it. And then 4910?
[AGENT][NEUTRAL] 1 for 6 months.
[CUSTOMER][NEUTRAL] On to 6 months. And then for the
[CUSTOMER][NEUTRAL] General anesthesia 9223. Is this a covered service?
[AGENT][NEUTRAL] I'm not finding that code.
[CUSTOMER][NEUTRAL] All right, not covered. Got it. And then for implant 6010, is this covered?
[AGENT][NEUTRAL] Oh, it's not covered.
[CUSTOMER][NEUTRAL] All right. Implants, oral surgery, general anesthesia, and also are not covered. Got it. Thank you very much uh for all the information. And is there any history at all for this patient for the ones that are covered?
[AGENT][NEUTRAL] Uh, just the maximum used.
[CUSTOMER][NEUTRAL] Oh, so no history.
[CUSTOMER][NEUTRAL] Like for the FMX panel.
[AGENT][NEUTRAL] Mm OK.
[AGENT][NEUTRAL] Uh, no, I don't see any history.
[CUSTOMER][NEUTRAL] All right. No history for the patient. Uh, nothing for uh exam by doing and proofy also?
[AGENT][NEUTRAL] I'll have to, I have to look my code. Do you have the codes?
[CUSTOMER][NEUTRAL] Oh yes. 0120.
[CUSTOMER][NEUTRAL] 0274 1110.
[CUSTOMER][NEUTRAL] And then 4341 and 4910.
[AGENT][NEUTRAL] Um, uh, we'll have to slow down a little bit. OK, so fight wings, yes, that was done 226, 25.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] What was the other code?
[CUSTOMER][NEUTRAL] 2 26 25.
[CUSTOMER][NEUTRAL] OK. Um, FMX pan on history. 0120.
[AGENT][NEUTRAL] No history.
[CUSTOMER][NEUTRAL] All right. Uh 11:10.
[AGENT][NEUTRAL] 226 25.
[CUSTOMER][NEUTRAL] 2 26 2025. And then for 4341?
[AGENT][NEUTRAL] No history.
[CUSTOMER][NEUTRAL] Uh, and then 4910.
[AGENT][NEUTRAL] No history?
[CUSTOMER][POSITIVE] All right, great then. Thank you so much. That's all the uh history that I needed for this patient. You've provided all the information to check for the group uh group number, is it 17626?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] And the group num uh the group name here would be?
[AGENT][NEUTRAL] Universal Trucking, Stevens Transport.
[CUSTOMER][NEUTRAL] Universal tracking.
[CUSTOMER][NEUTRAL] Trucking? Trucking. Stevens Transport. Universal Trucking Stevens Transport.
[AGENT][NEUTRAL] Trucking. Yes, trucking.
[AGENT][POSITIVE] Yes, correct.
[CUSTOMER][NEUTRAL] All right, great. Thank you so much. And then to check for the claims address, is it the [PII].
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] And the fee schedule here would be?
[AGENT][NEUTRAL] Based on what's reasonable and customary.
[CUSTOMER][POSITIVE] Got it. Thank you very much, uh, [PII], once again for your help. You have a wonderful day and bye for now. Thank you.
[AGENT][POSITIVE] Thank you for calling ATS.
[AGENT][POSITIVE] You too. Thank you.
[CUSTOMER][NEUTRAL] Right, I know.