AccountId: 011433970860
ContactId: c07a0bbb-8206-41a4-8de8-c83e54ffbb95
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 904890 ms
Total Talk Time (AGENT): 430905 ms
Total Talk Time (CUSTOMER): 260110 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/23/c07a0bbb-8206-41a4-8de8-c83e54ffbb95_20250423T19:39_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yes, I wanted to call and see if the patient is in, if we're in the network with their insurance, ma'am.
[AGENT][NEUTRAL] OK, sure, I can assist you with that information. May I have your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Is that [PII] or [PII]?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK. And um what is the name of the facility you're calling from, Miss [PII]?
[CUSTOMER][POSITIVE] Dream smells gentle.
[AGENT][NEUTRAL] OK. May I have the patient's policy number?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] 02558130
[AGENT][NEUTRAL] And may I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] [PII], and then there's some more family members. Hold on one second. Um
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] I'm sorry, ma'am. Give me one second, I apologize.
[AGENT][POSITIVE] That's OK. Take your time.
[CUSTOMER][POSITIVE] Thanks.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Yeah, his birthday is [PII].
[CUSTOMER][NEUTRAL] And then um the other one is, I'm trying to pull that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Let's see here, uh, where did it go?
[CUSTOMER][NEUTRAL] Oh I clocked a lot out of it one second.
[CUSTOMER][NEUTRAL] I'm trying to find it. I clicked out of the thing. I'm trying to scroll down to find the text.
[AGENT][POSITIVE] Yes, take your time.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][POSITIVE] Thank you, appreciate it.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Here we go.
[CUSTOMER][NEUTRAL] The other patients are [PII], [PII].
[CUSTOMER][NEUTRAL] And [PII] went to [PII].
[AGENT][NEUTRAL] OK, thank you. All right, Ms. [PII], uh, this particular policy is one of our dental policies. This one doesn't have any network. Um, we pay on the usual and customary rates, UCR.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Do you need a breakdown of benefits faxed over to you or do you need a specific information?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I can get a fax back and then also can I ask you a few questions just in case you're not on the fax back.
[AGENT][NEUTRAL] Sure, go ahead.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I just wanted to get, well, can you just give me a breakdown over the phone?
[AGENT][NEUTRAL] Yes, I can. All right, and before I give you any benefit information, I need to let you know that this is not a guarantee of payment, just a verification of coverage, and that's just a disclaimer.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And we have a calendar year maximum of 1500 per covered person per calendar year.
[AGENT][NEUTRAL] Um, we also have a $50 deductible or $150 per family, and deductible does not apply to preventative. Preventives are covered 100%. Radiograph FMX is covered at 80%.
[AGENT][NEUTRAL] Basic expense and basic restorative expenses cover 80%. Major service including endodonics, periodontics, prosthodontic repair, and or surgery are at 40% after the 12 month waiting period, which it looks like the waiting period is gonna be over on [PII]. Um, for the frequencies, um, we have cleanings once every 6 months.
[AGENT][NEUTRAL] Exams, 2 for 12 month period.
[AGENT][NEUTRAL] Bite wings once for 12 month period.
[AGENT][NEUTRAL] For my x-rays or panels are once every 5 years.
[AGENT][NEUTRAL] and bridges are once every 7 years per tooth. Impartial and dentures are once.
[CUSTOMER][NEUTRAL] What was that?
[AGENT][NEUTRAL] Um, the crowns and bridges.
[CUSTOMER][NEUTRAL] Crows, OK, your phone's cutting out. It's like you're kind of wobbly 1 in 7 years, OK.
[AGENT][NEUTRAL] Yeah, once in 7 years per tooth. And then the partial indentures is once every 5 years.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And that's gonna be on majors, which is 40% after the 12 month waiting period.
[AGENT][NEUTRAL] Um, the policy does have a missing tooth cloths.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, orthodontic treatment is not covered.
[AGENT][NEUTRAL] And implants placement, removal, or all um service are not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so 60 1060, 57, 60, 59 are not covered.
[AGENT][NEUTRAL] Implants are not covered, correct.
[CUSTOMER][NEUTRAL] OK. And then um.
[CUSTOMER][NEUTRAL] Can I ask you some codes and ask you um the frequency on the codes I have like 5 or 6 codes. Is that OK?
[AGENT][POSITIVE] Sure, yes, I need them one by one if you don't mind.
[CUSTOMER][NEUTRAL] OK, 4910.
[AGENT][NEUTRAL] All right, so 4910 is going to be on antibiotics, which is major and it's gonna be after the 12 month waiting period. Um, so for this one it's once every 6 months.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then um the next code is 4341.
[AGENT][NEUTRAL] You said 43, 41?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK. For the 4341, that's on periodontics, which is a 40% after 12 month waiting period, and that one, the limitation on that one is going to be maximum of 1 in quad for 24 months.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Of 4 quad same day or only 2 quads?
[AGENT][NEUTRAL] You can do all 4.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 4381
[AGENT][NEUTRAL] OK, 4381, that's also gonna be under the periodontics, which is 40% after the 12 month waiting period. Um, for that one, there is no limitation.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, our exclusive guards covered 9944?
[AGENT][NEUTRAL] No, 9944 is not covered.
[CUSTOMER][NEUTRAL] OK, and then um 2740.
[AGENT][NEUTRAL] 2740. That is the crown and that's gonna be under major services which is gonna be covered after the 12 month waiting period at 40% and the limitation on that one will be.
[AGENT][NEUTRAL] Let's see, limited to patients aged [PII] and over a maximum of 1 per 7 year period.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then did that, does the 2740 downgrade to like a 2791?
[AGENT][NEUTRAL] We don't downgrade.
[CUSTOMER][NEGATIVE] And same with composites that's what the composer composites doesn't grow go to amalgam.
[AGENT][NEGATIVE] No, we don't wanna downgrade or upgrade.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And um let's see, um 4346.
[AGENT][NEUTRAL] OK, 4346 is not covered or it's not listed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK, and 43, 4355.
[AGENT][NEUTRAL] 355.
[AGENT][NEUTRAL] OK, 4355 is going to be on periodonics, which is gonna be 40% after the 12 month waiting period, and this one has the same limitation as the one prior, which is um the maximum of 1 each quad for 24 months.
[CUSTOMER][NEUTRAL] How's your day going today?
[CUSTOMER][NEUTRAL] The 4355?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] The 50 you said once for quad for 2 a month.
[AGENT][NEUTRAL] Yes, 1 is quad for 24 months.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, oh, last code, sorry, 7953.
[AGENT][NEUTRAL] 7953 is not listed on the coverage service.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, that means not covered, huh?
[AGENT][NEUTRAL] OK OK.
[CUSTOMER][NEUTRAL] OK. So you said that there's a waiting period, 12 uh waiting period, and it's up on [PII]. So in other words, they can only have preventive and diagnostic services and diagnostic services, PAOs, FMXs, by wings, PAs are 80%.
[AGENT][NEUTRAL] Um, the FMX and panel is 80%. By wins is under preventative, which is 100%.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then the composites like 2391, what is the frequency on that 124 months or 36 months?
[AGENT][NEUTRAL] Which one again? What's the code?
[CUSTOMER][NEUTRAL] 2391, 2392. I just didn't know if it's like 1 in 24 months or 1 in 36 months.
[AGENT][NEUTRAL] 81.
[CUSTOMER][NEUTRAL] Composite
[AGENT][NEUTRAL] OK, let me, let me get that one.
[AGENT][NEUTRAL] Replace it, if it's existing in place for 24 months.
[CUSTOMER][NEUTRAL] OK. So all of those um
[CUSTOMER][NEGATIVE] All of those codes, even like feelings, they're not covered. Major and feelings aren't covered only the preventive is covered right now.
[AGENT][NEUTRAL] No, feelings are covered as um basic and basic distortive. Right now what he qualify or they qualify as a family is preventative radiograph FMX, basic expense and basic restorative. Any fillings, simple extraction, radiograph FMX, and preventative service.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK, that makes sense. Major work, yes, one year. OK. OK. And then one more code, I'm sorry, now one more code I promise 0 140. I didn't know if it had its own frequency or not or if it's shared.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 140. OK, yeah, that one does share frequency. So it is going to be, let's see.
[AGENT][NEUTRAL] Alright, so that one is on their basic expense, which is 80%, and that one is limited to two or evaluation procedures and any combination of 120, 140, 150, 160, or 180 per 12 month period.
[CUSTOMER][NEUTRAL] 212.
[CUSTOMER][MIXED] OK, but that's the only one that's basic is limited, but the cop exam periodic or 100%.
[AGENT][NEUTRAL] Um, which ones? I'm sorry, can you repeat?
[CUSTOMER][NEUTRAL] 0 15002 1500 120.
[AGENT][NEUTRAL] OK, 120. OK, let me check the 120.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So the 120 is going to be under preventative. So that one is under preventative, um, the 13 140 is the one we just said, which is basic, um, 150 is going to be under.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Basic, no, that one is preventative. I'm sorry, that one is preventative, um.
[AGENT][NEUTRAL] go back 160.
[AGENT][NEUTRAL] 160 on their basic and I think 180 is on your basic.
[AGENT][NEUTRAL] Let me check.
[CUSTOMER][NEUTRAL] You said 120 is under preventative.
[AGENT][NEUTRAL] Yes, 120 is under preventative.
[CUSTOMER][NEUTRAL] The same with 150 preventative.
[AGENT][NEUTRAL] Correct, yes. 120 and 150 is under preventative.
[CUSTOMER][NEUTRAL] OK. What was your name?
[AGENT][NEUTRAL] My name is [PII]. That's [PII] [PII]. That's initial is [PII].
[CUSTOMER][NEUTRAL] [PII], OK. 00, so M, OK. Um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, mhm.
[CUSTOMER][NEUTRAL] Um, does the patient have any history, or the patient have any history or anything, or?
[AGENT][NEUTRAL] Um, and let me check one moment.
[AGENT][NEUTRAL] OK, so there's no history for [PII], the father. Um, let me check the dependent.
[AGENT][NEUTRAL] There's no history for rot need dependence.
[AGENT][NEUTRAL] And there's no history for Aiden.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Perfect. Thank you, ma'am. I appreciate your time today.
[AGENT][NEUTRAL] You're welcome. Is there anything else I may help you with today, Ms. [PII]?
[CUSTOMER][NEUTRAL] No, if you wanna send over that fax, you can do that too. Would you like that way I have a hard copy. Can I send you the fax number?
[AGENT][NEUTRAL] Uh, go ahead with the fax number. I'll have to send it before I let you go. Is that OK?
[CUSTOMER][NEUTRAL] That's fine. It's gonna be [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, one moment, let me get this for you. Is it OK if I put just uh the name of the main holders?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] I don't care whatever is easier for you.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] What is he? He doesn't matter to me at all.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Bear with me.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and the fax was [PII], correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, I went ahead and send that over. Is there anything else I may help you with today?
[CUSTOMER][POSITIVE] Oh thank you, so you have a wonderful day.
[AGENT][POSITIVE] You as well. Have a good afternoon. Thank you for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Bye.