AccountId: 011433970860
ContactId: c120d779-b3a5-47a9-9378-acb1f83a1e01
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 691440 ms
Total Talk Time (AGENT): 265368 ms
Total Talk Time (CUSTOMER): 157032 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/20/c120d779-b3a5-47a9-9378-acb1f83a1e01_20250620T19:00_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, I'm calling from uh uh provider's office to verify eligibility and benefits.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the eligibility and benefits. And may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII] and our call number is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Policy number is 941529.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And I am showing that the policy is active. It's been effective since [PII].
[AGENT][NEUTRAL] And did you need a copy of the fax back or you have particular questions about it?
[CUSTOMER][NEUTRAL] Um, I do have, uh, some questions, but I also would like to fax back.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so I have the fax back here. So on the fax back, uh, well, first what's a good fax number for you? I'm sorry.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, hold on one moment. I'm faxing that over to you now.
[CUSTOMER][NEUTRAL] OK, I just want to confirm we're also in network with this insurance.
[AGENT][NEUTRAL] Um, this insurance doesn't have a network, so, uh, hold on one moment, the box just popped up to in the fax, and then I can hold on one second.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so there's no um network for this policy. So you'll see the calendar year maximum deductible and then all the frequencies, all the limitations, all the ways to file a claim, and then there's a list of covered codes and the amount that would be applied to that code. If the code you're looking for isn't on this list, it wouldn't be covered by the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, is this a discount plan by any chance or no?
[AGENT][NEUTRAL] No, it's not a discount plan.
[CUSTOMER][POSITIVE] Oh OK, oh OK, I just wanted to make sure I'm sorry.
[AGENT][NEUTRAL] No, you're fine.
[AGENT][NEUTRAL] So let me know, uh, well, we usually say to give the faxes about an hour, but did you have any like particular questions?
[CUSTOMER][NEUTRAL] Oh yes, I wanted to know um the percentages each class is covered at and the annual max and this couple quotes to see if the patient would be covered for on Monday.
[AGENT][NEUTRAL] OK, um, well, yes, that is on the fax bag, but if you want to go over it over the phone, I can go over it with you.
[CUSTOMER][POSITIVE] Yes, that's what that's what I would like thank you.
[AGENT][NEUTRAL] OK, so the calendar year max is $1000.
[AGENT][NEUTRAL] The deductible is $50 per person up to $150 per family.
[AGENT][NEUTRAL] The deductible doesn't apply to exams or pro fees?
[AGENT][NEUTRAL] And did you need to know the frequencies?
[CUSTOMER][NEUTRAL] Um, has he used any of his maximum to this day?
[AGENT][NEUTRAL] Hold on 1 2nd.
[AGENT][NEUTRAL] OK, so so far for [PII], he has not used any of the max or met the deductible.
[CUSTOMER][NEUTRAL] OK, and the preventative is covered at what percentage?
[AGENT][NEUTRAL] Um, so again, this isn't that type of policy, it's just codes and what will pay towards that code.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] So there's no um like percentages, 100%, 80, 40.
[AGENT][NEUTRAL] Trophies and cleanings are once every 6 months and
[AGENT][NEUTRAL] Um, hold on one second.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the fax back will include all these codes that the um that the insurance covers for, correct?
[AGENT][NEUTRAL] Right, it has a whole, um, it's about, yeah, it has a whole list of codes and then the benefit amount for that code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and um is this patient eligible for a comprehensive exam for Monday?
[AGENT][NEUTRAL] Um, do you have a code for that?
[CUSTOMER][NEUTRAL] The code is D0150.
[AGENT][NEUTRAL] 150. OK, hold on one moment.
[AGENT][NEUTRAL] 6 months.
[AGENT][NEUTRAL] Um, the last day of service for 00150 was [PII], so yes, he, he's overdue.
[CUSTOMER][NEUTRAL] So he had a D0150 March of this year.
[AGENT][NEUTRAL] No, [PII].
[CUSTOMER][NEUTRAL] 2014? Oh, OK. Sorry.
[AGENT][NEUTRAL] You're fine.
[CUSTOMER][NEUTRAL] And is this code covered at 100%?
[AGENT][NEUTRAL] We don't do percentages for this policy.
[AGENT][NEUTRAL] So, for example, code 0150, um, that code pays out.
[CUSTOMER][POSITIVE] OK, I'm sorry.
[AGENT][NEUTRAL] $89.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what is the frequency for this?
[AGENT][NEUTRAL] It is.
[AGENT][NEUTRAL] Once every 6 months.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Is he covered for um D0210 or D0330?
[AGENT][NEUTRAL] 0 to 10, um, can pay up to $126.
[AGENT][NEUTRAL] And 0330 can pay up to $62.
[CUSTOMER][NEUTRAL] And what's the frequency for for both?
[AGENT][NEUTRAL] Oh, I'm sorry, hold on one second. Let me make sure I gave you that right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 0330 is $100 my apologies.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then I, I missed the last code you said.
[CUSTOMER][NEUTRAL] What's the frequency for for uh the pan and FMS?
[AGENT][NEUTRAL] Uh, full mouth X-rays and panels are once every 3 years.
[CUSTOMER][NEUTRAL] And does he have any history on file for for those two codes?
[AGENT][NEUTRAL] It was 0210 and 0330?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Is that correct? OK, hold on one moment.
[AGENT][NEUTRAL] Um, 210 was [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let me see the other one.
[AGENT][NEUTRAL] And there's no claim on or we haven't processed anything for 0330.
[CUSTOMER][NEUTRAL] OK, and the last code that I have is D 1206. Is there an age limitation for that for that code?
[AGENT][NEUTRAL] Um, 1206 is not a cover code on the policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So he, because it's um it's not like percentages or basic or nothing. I'm assuming there's no waiting period or missing tooth cloth.
[AGENT][NEUTRAL] Um, let me see.
[AGENT][NEGATIVE] There is a missing tooth cloth. There's no waiting period.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the mailing address is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm. Um, so our mailing, our, our new claims mailing address, let me know when you're ready.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] OK, it's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] And what is the payer ID?
[AGENT][NEUTRAL] 60801.
[CUSTOMER][NEUTRAL] And is this the same address for pre-authorizations as well?
[AGENT][NEUTRAL] Um, prior authorizations and pre-estimates are not required, um, but if you'd like to send one in, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright, thank you so much for your help. um, all I need is just the call reference number and then I'll be all set.
[AGENT][NEUTRAL] Alright, so there's no call reference number, but you can use my name in today's date. And again, that's [PII], first initial and my last name is [PII].
[CUSTOMER][POSITIVE] All right thank you so much.
[AGENT][POSITIVE] You're very welcome, [PII]. Thanks for calling APL. I hope you have a great weekend.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you, bye bye.