AccountId: 011433970860
ContactId: c3537072-5026-4081-bf0e-ff710aaaf790
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 653940 ms
Total Talk Time (AGENT): 299804 ms
Total Talk Time (CUSTOMER): 166328 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/12/c3537072-5026-4081-bf0e-ff710aaaf790_20250612T18:33_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi so my name is [PII]. I'm trying to get the eligibility and breakdown for a patient.
[AGENT][POSITIVE] OK, sure. I can assist you with eligibility and benefits for patient, Miss [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yeah, of course it's [PII].
[AGENT][NEUTRAL] OK, thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yeah, I only have their social. Is that OK?
[AGENT][NEUTRAL] Um, yes, go ahead.
[CUSTOMER][NEUTRAL] OK perfect it's 497250886.
[AGENT][POSITIVE] OK. Thank you.
[AGENT][NEUTRAL] LS 497250886.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, what's the name of the patient?
[CUSTOMER][NEUTRAL] It's going to be for his dependent [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Here we go.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, and you need the eligibility and benefit given to you verbally or faxed over to you, Miss [PII]?
[CUSTOMER][NEUTRAL] Uh, verbally, please.
[AGENT][NEUTRAL] OK, right, and this is for?
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] OK, 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, and we have an effective date of [PII]. It is active at the moment, and this one has a calendar year maximum of $1500 per covered person per calendar year with a $50 deductible or a $150 deductible per family.
[AGENT][NEUTRAL] Um, for the, um, frequencies, we have, see, one moment.
[AGENT][NEUTRAL] OK, so preventative is cover 100%, radiograph FMX is covered at 80%, basic expense and basic restorative expenses covered at 80%.
[AGENT][NEUTRAL] Then we have major services including endodontics, periodontics, prosthodontic repair, and oral surgery. They're all 40%.
[AGENT][NEUTRAL] And there was a 12 month wait.
[CUSTOMER][NEUTRAL] They're 50% or 40%?
[AGENT][NEUTRAL] 40
[CUSTOMER][POSITIVE] 40% OK perfect let me add that on there.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then you said a major would be endo oral surgery, and periodontics, correct?
[AGENT][NEUTRAL] Correct. Major includes endodontics, periodontics, repair, and or surgery. Mhm.
[CUSTOMER][NEUTRAL] OK perfect just wanted to confirm and then FMX and panel would also be under basic, is that correct?
[AGENT][NEUTRAL] It is under radiograph and SMX which is 80%.
[CUSTOMER][NEUTRAL] OK, is FMX and panel the only one that's under 80% or would by Wings also be under basic?
[AGENT][NEUTRAL] Um, um, by wings is under preventative, which that's 100%.
[CUSTOMER][POSITIVE] OK perfect just wanting to confirm thank you for that.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] And then from there um before I get any frequencies um are we gonna be in network with this patient's plan?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] There's no network.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] There's no network?
[AGENT][NEUTRAL] Correct, there's no network. Mhm.
[CUSTOMER][NEUTRAL] OK, and then could I get the payer ID number?
[AGENT][NEUTRAL] Sure, the payer ID number is 60801.
[CUSTOMER][NEUTRAL] 60081 correct?
[AGENT][NEUTRAL] 60801. Yes. Mhm.
[CUSTOMER][POSITIVE] OK perfect thank you.
[AGENT][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Um, and then from there, could I get the group name and group number for this patient's plan?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] OK, the group name is Universal Trucking DMJ.
[AGENT][NEUTRAL] Intermodal.
[AGENT][NEUTRAL] And the group number.
[CUSTOMER][NEUTRAL] Universal Trucking.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] D N J
[AGENT][NEUTRAL] Intermodal.
[CUSTOMER][POSITIVE] Intermotal OK.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] And the group number is 15197.
[CUSTOMER][POSITIVE] Perfect, thank you. Do you guys have a per a specific fee schedule that you go you guys go under?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um, you'll be paying on the usual and customary rate UCR.
[CUSTOMER][NEUTRAL] OK, and then could I get the frequency for FMX and panel?
[AGENT][NEUTRAL] Mhm, sure.
[AGENT][NEUTRAL] Excuse me. OK, so, uh, FMX and panels is once every 5 years.
[CUSTOMER][NEUTRAL] And the frequency for bite wings?
[AGENT][MIXED] OK, but wings is once per 12 month period.
[CUSTOMER][NEUTRAL] How about exams?
[AGENT][NEUTRAL] Alright, extends are 2 for 12 month period.
[CUSTOMER][NEUTRAL] And pro prophylaxis?
[AGENT][NEUTRAL] Profies and cleaning is once every 6 months.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] And then um can I get the is fluoride and sealants covered under this plan?
[AGENT][NEUTRAL] There is an age limit.
[AGENT][NEUTRAL] Let me get the one for the.
[AGENT][NEUTRAL] Excuse me for a slow ride.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Limited to dependent children under the age of [PII] and it's gonna be maximum of 1 procedure for 12 months.
[AGENT][NEUTRAL] And then for this feelings is limited to dependent children aged [PII], application made to the molar teeth only, the maximum of one procedure for 36 months.
[CUSTOMER][NEUTRAL] OK perfect and could I get the frequency for um SRP 4341 and can all four quads be done same day?
[AGENT][NEUTRAL] Yes, they all can be done the same day. Um, excuse me, let me see.
[AGENT][NEUTRAL] A maximum of 1 each squat for 24 months.
[CUSTOMER][NEUTRAL] Thank you and could I get the frequency for crowns 2740, and are they paid on seat date or prep date?
[AGENT][NEUTRAL] Hm
[AGENT][NEUTRAL] It's going to be seat date.
[AGENT][NEUTRAL] And the frequency on this one is.
[AGENT][NEUTRAL] Maximum of 1 per 7 year period.
[CUSTOMER][NEUTRAL] OK perfect thank you and could I get the uh would that also be the same for dentures as well 1 in 7 years?
[AGENT][NEUTRAL] Um, for dentures, let me check on that one. denture partial and dentures is once every 5 years.
[CUSTOMER][NEUTRAL] OK, thank you, and then could I get the frequency for perio maintenance 4910?
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, 4910 is once every 6 months.
[CUSTOMER][NEUTRAL] Thank you. Is nitros covered under this plan 90,230?
[AGENT][NEUTRAL] 222.
[AGENT][NEUTRAL] Yes, 9230 is going to be covered under, let's see.
[AGENT][NEUTRAL] That's on the major service, so that's 40%.
[AGENT][NEUTRAL] There's no limitation on that one.
[CUSTOMER][NEUTRAL] And is there a frequency?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Thank you. And then is there implant coverage under this plan?
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] No, no implant.
[CUSTOMER][POSITIVE] Thank you and are there any waiting periods missing tooth cloths or downgrades on fillings?
[AGENT][NEUTRAL] We don't downgrade. Um, there is a missing two clause. There's no waiting period they're out of the waiting period.
[CUSTOMER][NEUTRAL] OK, and is there any history under this plan?
[AGENT][NEUTRAL] For the this number, let me check one moment.
[AGENT][NEUTRAL] OK, for the, the last prophy we have is [PII]. The last panel was [PII]. The last fight win was also the same date.
[AGENT][NEUTRAL] Last oral evaluation was the same day.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] And it looks like that's gonna be it for her.
[CUSTOMER][POSITIVE] OK perfect thank you and could I get your reference number and that should be it.
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's state. Do you need the spelling of my name or any other information?
[CUSTOMER][NEUTRAL] Uh yes, please.
[AGENT][NEUTRAL] OK, that's S [PII].
[CUSTOMER][POSITIVE] OK perfect thank you so much for your help today.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] You're welcome and thank you for calling ATO. Have a good day, Miss [PII].
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you