AccountId: 011433970860
ContactId: ab6f09d6-a2cb-4dae-9665-ebc7951bd488
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 329720 ms
Total Talk Time (AGENT): 165398 ms
Total Talk Time (CUSTOMER): 127471 ms
Interruptions: 1
Overall Sentiment: AGENT=1.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/ab6f09d6-a2cb-4dae-9665-ebc7951bd488_20250114T22:42_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] Hi [PII], my name is [PII]. I am calling to get information on a patient's dental benefits.
[AGENT][POSITIVE] OK, yeah, I'd love to help you with some dental benefits today. Do you mind if I get a good call back number?
[CUSTOMER][NEUTRAL] Sure it's [PII].
[AGENT][POSITIVE] Wonderful and uh the policy number for your patient?
[CUSTOMER][NEUTRAL] I'm sorry, could you repeat that? My other, my phone beeped out because my other line was ringing.
[AGENT][NEUTRAL] No, you're OK. What's your member's policy number today?
[CUSTOMER][NEUTRAL] Um, it's 02439172.
[AGENT][POSITIVE] Wonderful.
[AGENT][NEUTRAL] And your patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Patient is [PII]. Date of birth [PII].
[AGENT][POSITIVE] Perfect and I can send you a fax back of benefits for this patient if you'd like.
[CUSTOMER][NEUTRAL] Um, actually I just have a couple specific questions.
[AGENT][NEUTRAL] OK, yeah, let me pull up his um policy document real quick for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what questions can I help you with?
[CUSTOMER][NEUTRAL] Um, so I need to just confirm that he's eligible like as of today. His appointment with us is tomorrow and then find out his yearly max and deductible amounts and then I have two procedure codes to check on.
[AGENT][NEUTRAL] OK, you bet you. Um, so [PII], or miss, I can so sorry, [PII], um, I read his last name as his first name. Uh, he is current and active. He's been effective with us since [PII]. I do wanna let you know any benefit information I give you over the phone is just a verification of coverage and not a guarantee of payment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And he has a $500 calendar year maximum with a $50 deductible. His deductible does not apply to preventative services.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Has he used anything yet this year?
[AGENT][POSITIVE] That is a wonderful question. Let me take a look at that.
[AGENT][NEUTRAL] Um, no, he's not used anything so far for his calendar year benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so then I have two procedure codes to check on to see if they're covered on his plan, and if so, what percentage and if there's frequency limits.
[AGENT][NEUTRAL] OK, perfect. And what are the two quotes we want to look at today?
[CUSTOMER][NEUTRAL] It's um 0140 and 0364.
[AGENT][NEUTRAL] 0364.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Alright, so 0364 is not covered under his policy. 0140 is covered under his policy under basic, so it'd be covered at 80%, um, and then it is sharing a frequency with 01200150 and 0160, which limits to two evaluations in any combination per 12 month period.
[CUSTOMER][NEUTRAL] OK, yeah, weird.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 2 per 12 months, OK.
[CUSTOMER][NEUTRAL] Actually, while I have you on the phone, we're just doing an email tomorrow. Can I get a couple more codes in case he does need to come back to us for treatment information on a couple other codes? OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Absolutely.
[CUSTOMER][NEUTRAL] Um, it would be 33, let's see.
[CUSTOMER][NEUTRAL] 3310.
[CUSTOMER][NEUTRAL] 3346 and 2330.
[AGENT][NEUTRAL] Alright, 3310 is not covered and then 3346 you said?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh, yes, that would also not be covered because it's endo as well then and then 2330.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 2330 is covered under basic restorative uh 80% and then it has two limitations. Let me pull those for you.
[CUSTOMER][NEUTRAL] 80%.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Um, it looks like we're limited to maximum 1 each tooth for 24 months and replace existing if only in place for 24 months.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, and then is this, um, plan based off of like usual customary amounts or is it a fee schedule type plan?
[AGENT][NEUTRAL] Um, yeah, this plan actually follows the Carrington PPO network fee schedule. However, utilization of a provider within the Carrington network is not required.
[CUSTOMER][NEUTRAL] OK, yeah, and we're not in network so then would it be based off UCR amounts then or?
[AGENT][NEUTRAL] No, it's still gonna follow their fee schedule.
[CUSTOMER][NEUTRAL] Are you still just based off of their fee schedule, OK.
[AGENT][NEUTRAL] Yep, yep.
[CUSTOMER][NEUTRAL] Are you able to tell me if our charges are within those amounts? Do you have access to that?
[AGENT][POSITIVE] I don't. I'm so sorry.
[CUSTOMER][NEUTRAL] You don't, OK, that's OK and then um.
[CUSTOMER][NEUTRAL] What is the mailing address for claims for this plan?
[AGENT][NEUTRAL] You bet you the mailing address it's um you can make it out to American Public Life claims or APL claims um and we're gonna go to [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] In [PII].
[AGENT][NEUTRAL] And our zip code here is [PII].
[CUSTOMER][NEUTRAL] OK, and then what about an electronic payer ID as well?
[AGENT][NEUTRAL] Oh yes, 60801.
[CUSTOMER][POSITIVE] OK perfect I think that gives me everything I need thank you [PII]. I appreciate your help today.
[AGENT][POSITIVE] Yes, absolutely, it's my pleasure, and Miss [PII], I hope you have a wonderful day and then I cannot talk, girl. I'm so sorry. Have a wonderful day. Thank you for calling.
[CUSTOMER][POSITIVE] Thanks.
[CUSTOMER][NEUTRAL] That's OK
[CUSTOMER][NEUTRAL] All right bye bye.
[AGENT][POSITIVE] Bye-bye. Thanks.