AccountId: 011433970860
ContactId: b61d3490-f690-48e0-8d99-c78f7eb0ba6e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 735299 ms
Total Talk Time (AGENT): 355589 ms
Total Talk Time (CUSTOMER): 204112 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/b61d3490-f690-48e0-8d99-c78f7eb0ba6e_20250207T16:02_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][POSITIVE] Yes, hi, I'm trying to get some um.
[CUSTOMER][NEUTRAL] I'm trying to get to the dentist so they can do a root canal, and I need to know, they won't tell them what percentage it is that they're paying out. So they're just saying 80%, but we need to know 80% of what.
[AGENT][NEUTRAL] Of the UCR usually. Uh, what's your, what's the policy number, please?
[CUSTOMER][NEUTRAL] Um, I can, I can, it's 124.
[CUSTOMER][NEUTRAL] 651 9
[AGENT][NEUTRAL] OK, thank you. And your name is?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and Ms. [PII], verify your date of birth and mailing address, please.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] OK, and do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you so much. But um as far as with your dental policy, it pays by UCR uh percentage. So if they, if it's for major service like a root canal, uh, the max payable is up to 50%, or I'm sorry.
[AGENT][NEUTRAL] Let me double check
[CUSTOMER][NEUTRAL] Well, she, she gave me the numbers to um to give to you.
[AGENT][NEUTRAL] Or the procedure codes they're gonna use?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] So the first one is D0140.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mm mm mm mm mm.
[AGENT][NEUTRAL] Oh, did she give you any other codes or just that one?
[CUSTOMER][NEUTRAL] No, I've got 5 of them.
[AGENT][NEUTRAL] OK, give them to me.
[CUSTOMER][NEUTRAL] OK, and the second one it's D0220.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The third is D 0364.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, 4th 1 is D 0460.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the 5th it's D3320.
[AGENT][NEUTRAL] OK, and let me see.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK one moment.
[AGENT][NEUTRAL] OK, the first code, that's um basic, so it pays 80.
[AGENT][NEUTRAL] The other is a TA X-ray, pays 80% of.
[CUSTOMER][NEUTRAL] Wait a minute, hold on a second. So, give me 1 2nd.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] So I just need to know what how how much I need to pay is that what you're giving me or?
[AGENT][NEUTRAL] No, we don't give that information. The only thing I can verify if it's considered major or basic services, and there's a percentage of that UCR. Uh, what UCR means is that general area for that dentist, there's a usual customary reasonable fee. And depending on whether it's a preventive major or basic services, we pay a percentage of that UCR up to your max benefit for the year.
[CUSTOMER][NEUTRAL] OK, so the first, the first one you're paying 80%, is that what you're saying?
[AGENT][NEUTRAL] Uh, the first one is considered basic, so it pays at 80% of UCR. Uh, the second one as well. Um, the other code that's 0364, I don't show it in your policy, so it, it's not covered. The other one is basic, and for the code, that is
[AGENT][NEUTRAL] Major, so it pays at 40% of UCR.
[CUSTOMER][NEUTRAL] Which which one pays up 40%?
[AGENT][NEUTRAL] The 3320, uh, that's the code they use for the root now.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So you guys pay
[AGENT][NEUTRAL] If you have the, oh, go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] So you guys pay 40% of the G3320.
[AGENT][NEUTRAL] Yes, ma'am. For major services, it pays at 40% of UCR.
[CUSTOMER][NEUTRAL] OK, and then what about the 0220?
[AGENT][NEUTRAL] Uh, the 0220 is an X-ray. It's just a PA X-ray, so it pays at 80% since it is considered basic.
[CUSTOMER][NEUTRAL] And then the 0460.
[AGENT][NEUTRAL] Uh, that pays at 80%.
[CUSTOMER][NEUTRAL] But you don't have a code for the, the scan, the CPT scan the 0 the D0364.
[AGENT][NEUTRAL] Yes, ma'am. It's not, I don't show it in the policy, so it's not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the
[CUSTOMER][NEUTRAL] They get I got the prices from them yesterday.
[CUSTOMER][NEUTRAL] So for the evaluation, she quoted $110 I mean for the 0140, she quoted $110.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then the 0220 they quoted $37 the 0364 they quoted 180, the 0460 is $68 and then the 3320 is $1300. Mhm.
[CUSTOMER][NEUTRAL] So what I would need to do is just total all of this and then take take and then I should kind of know what I'm paying on my end.
[AGENT][NEUTRAL] No, ma'am, not necessarily because it's not a percentage of how much they charge, it's the percentage of what, like I said with the usual customary reasonable rate in that Dennis area. If you have their zip code, I can kind of verify if the amount they're charged falls within that UCR amount.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEGATIVE] Well, these are the the prices that she said that they charge. This is without the insurance.
[AGENT][NEUTRAL] That's their price, but there's the, there's something called a usual customary reasonable rate, and that is in that area, that zip code from where that uh dentists have their office, there's a usual customary and reasonable rate.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] That is what the provider would typically use as far as um the prices for certain procedures, and we pay a percentage of that, not necessarily how much is charged, because they can have uh charge you like $100 for an exam, but the UCR amount could be $90. So it just depends on that zip code. So if you have the provider zip code, I can verify if it falls within that UCR amount in that area.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Yeah, let me, let me, let me get you the zip, the zip code.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Excuse me.
[CUSTOMER][NEGATIVE] It, it does, it does not make sense to me at all.
[CUSTOMER][NEUTRAL] OK, the zip code is [PII].
[AGENT][NEUTRAL] [PII]. OK, give me one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Same
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] Give me one moment. I'm gonna get the UCRI for each one, OK?
[CUSTOMER][POSITIVE] OK thanks.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And this is just a verification of coverage and not a guarantee of payment. Um, for that one, the 0140, um, showing the UCR amount is 140 and how much you said they, uh, they said they would charge for that code?
[CUSTOMER][NEUTRAL] 110.
[AGENT][NEUTRAL] So, OK, so it falls below the UCR amount. And so, let's see for 123.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK, and the max for that code we would pay is 9840.
[CUSTOMER][NEUTRAL] And that's for the 0220.
[AGENT][NEUTRAL] Uh, that's 0140.
[CUSTOMER][NEUTRAL] OK, you said the max you're paying is, is how much?
[AGENT][NEUTRAL] Um, 9840. That's 80% of that UCR amount.
[AGENT][NEUTRAL] Uh, for the 2.
[CUSTOMER][NEUTRAL] But OK, so what was, what was the 140? I'm I'm trying to understand.
[AGENT][NEUTRAL] The
[CUSTOMER][NEUTRAL] So they're they're charging 110 but you guys are only gonna pay up to what, what, what amount?
[AGENT][NEUTRAL] 9840.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] If they're charging less than 140, why do, why do they only pay 9040?
[AGENT][NEUTRAL] Because with the policy, as I say, we pay a percentage of the UCR amount. The UCR amount for that code is 123, so 80% of 123 is 9840.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, for the
[AGENT][NEUTRAL] 0220, uh, it's 3280.
[AGENT][NEUTRAL] So that's $80 that amount is 80% of $41 which is the UCR amount.
[CUSTOMER][NEUTRAL] You said $41?
[AGENT][NEUTRAL] Um, $41 is a UCR amount for that code and 80% of that is $3280 which is covered by our office.
[CUSTOMER][NEUTRAL] Mhm. OK.
[AGENT][NEUTRAL] Um, so 0460, uh, the UCR amount is $73.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] 80% of that is 5840.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And for the actual root canal, uh, the UCR amount is 1270 times the 40% of that UCR and that is 508 is the max payable.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, so how, how do I figure out what my portion would be?
[AGENT][NEUTRAL] Um, then I'm not sure. Uh, you can have the provider contact our office and if they need for us to send a fax back, we can, that gives the UCR amounts for either preventive basic or major services.
[CUSTOMER][NEUTRAL] I mean, I can give them the ones that you just gave me.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Mhm. You can give it to them and well, we can't figure out how much your out of pocket costs would be because you also do have a $50 deductible on the plan that is applied to anything but preventative services.
[CUSTOMER][NEUTRAL] And she
[CUSTOMER][NEUTRAL] OK, alright, let me try to call them.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] This
[AGENT][NEUTRAL] And is there anything else I can assist you with today, Ms. [PII]?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] No, no, I'm gonna try to call them.
[AGENT][POSITIVE] OK. Uh, thanks for calling APL. Have a great day.
[CUSTOMER][POSITIVE] Thanks, you too.
[AGENT][NEUTRAL] Yes, ma'am.