AccountId: 011433970860
ContactId: c4fb5db4-3298-44bf-a842-1c36b9c85e4f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 952010 ms
Total Talk Time (AGENT): 282989 ms
Total Talk Time (CUSTOMER): 191143 ms
Interruptions: 0
Overall Sentiment: AGENT=0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/10/c4fb5db4-3298-44bf-a842-1c36b9c85e4f_20250610T21:30_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII] and I was calling to get a breakdown of benefits for patients.
[AGENT][POSITIVE] I can help you with benefits, [PII]. Can I get a good call back number in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] Policy number is 01682012.
[AGENT][NEUTRAL] Alright, give me just one moment while I look that up.
[AGENT][NEUTRAL] Can I get you to verify the patient's name and date of birth for me please?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] Alright, I'm showing that this policy is active.
[AGENT][NEUTRAL] Were there any specific benefits that you needed inpatient or outpatient?
[CUSTOMER][NEUTRAL] Um, well, I wanted to verify that we're in network with his dental insurance. Are you able to see that information?
[AGENT][NEUTRAL] Sure, let me see. Would you like a fax back?
[CUSTOMER][POSITIVE] Um, if you're able to give me verbal, that'll be great.
[AGENT][NEUTRAL] OK, give me just one moment to pull it up.
[AGENT][NEUTRAL] Alright, um, so there is no in and out of network we just go, uh, based off of a percentage of UCR.
[AGENT][NEUTRAL] So are there specific codes um that you would like me to go over?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, and let me just start at the beginning. Can I get the claim's mailing address?
[AGENT][NEUTRAL] Sure, uh, the mailing address will be [PII].
[AGENT][NEUTRAL] In [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Hang on, I'm gonna ask you for that zip code one more time.
[CUSTOMER][NEUTRAL] Um, what was it?
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the payer ID?
[AGENT][NEUTRAL] 60801.
[CUSTOMER][NEUTRAL] Group number for this plan?
[AGENT][NEUTRAL] Let me check the group number.
[AGENT][NEUTRAL] It is 16068.
[CUSTOMER][NEUTRAL] Um, and then the group name?
[AGENT][NEUTRAL] Universal Trucking Hirschbach. And do you need me to spell that?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Just the last part.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] HIR.
[AGENT][NEUTRAL] S C H D A C H.
[CUSTOMER][NEUTRAL] OK, um, effective date for this one?
[AGENT][NEUTRAL] The effective date is [PII].
[CUSTOMER][NEUTRAL] Maximum?
[AGENT][NEUTRAL] OK, let me see what they're.
[AGENT][NEUTRAL] Their calendar year maximum is $1500.
[CUSTOMER][NEUTRAL] Deductible?
[AGENT][NEUTRAL] $50 per covered person, up to $150 per family.
[CUSTOMER][NEUTRAL] Is that we've done preventative?
[AGENT][NEGATIVE] Deductible does not apply to preventative expenses, no.
[CUSTOMER][NEUTRAL] And is this based on a calendar year?
[AGENT][NEUTRAL] Um, yes, ma'am. This is the calendar year maximum.
[CUSTOMER][NEUTRAL] Any waiting periods?
[AGENT][NEUTRAL] It looks like there's a 12 month waiting period for major expenses, endoonic expenses.
[AGENT][NEUTRAL] Periodontic expenses?
[AGENT][NEUTRAL] Prosthodontic repair expenses and oral surgery expenses.
[CUSTOMER][NEUTRAL] OK, dependent age coverage?
[AGENT][NEUTRAL] Um, let me see
[AGENT][NEUTRAL] Are you asking if it takes uh adults and children?
[CUSTOMER][NEUTRAL] Up until what age is the dependent covered?
[AGENT][NEUTRAL] Oh, let me see.
[CUSTOMER][NEUTRAL] Usually I think it's [PII], I just wanna confirm.
[AGENT][NEUTRAL] Yeah, I thought it was [PII] or [PII], but I don't know. Let me look that up.
[AGENT][NEUTRAL] Um, but I don't believe he has any.
[AGENT][NEUTRAL] Dependent so let me look.
[CUSTOMER][NEUTRAL] Actually I'm not
[CUSTOMER][NEUTRAL] another office.
[CUSTOMER][NEUTRAL] she
[CUSTOMER][NEUTRAL] 0
[AGENT][NEUTRAL] Alright, let me look that up for you real quick.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, I'm having to ask someone about that. Did you want to move on until I get that answer?
[CUSTOMER][NEUTRAL] Yeah, um, pre-authorization is it recommended or required?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, it is not a requirement.
[AGENT][NEGATIVE] So no.
[CUSTOMER][NEUTRAL] Um, preventative, could you give me what is covered at?
[AGENT][NEUTRAL] Preventative is covered at 100% of UCR.
[CUSTOMER][NEUTRAL] Basic.
[AGENT][NEUTRAL] 80% UCR.
[CUSTOMER][NEUTRAL] And does that include Perial endo NOS?
[AGENT][NEUTRAL] Uh, perdontic and endodontic, they're at 40%.
[AGENT][POSITIVE] And you were right, um,
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] It's 26 for dependents. Mhm.
[CUSTOMER][NEUTRAL] OK. And then oral surgery, is that 80?
[AGENT][NEUTRAL] Oral surgery is at 40.
[CUSTOMER][NEUTRAL] So all of them are.
[CUSTOMER][NEUTRAL] Prior extractions, are they a covered benefit?
[AGENT][NEUTRAL] I'm sorry, what was that?
[CUSTOMER][NEUTRAL] Prior extractions, are they covered?
[AGENT][NEUTRAL] Let me look
[AGENT][NEUTRAL] Um, would that be the missing tooth claws?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEGATIVE] Yes, this does have a missing tooth clause.
[CUSTOMER][NEUTRAL] OK, um, prosthetic replacement every how often? And is it paid on seat date?
[AGENT][NEUTRAL] Um, yes, this is paid on seat date, um, and implant placement, removal and all related services to that are not covered.
[AGENT][NEUTRAL] You just implants or digest something else, I apologize.
[CUSTOMER][NEUTRAL] Um, for crowns.
[AGENT][NEUTRAL] Oh, crowns.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] 2740 is one of.
[AGENT][NEUTRAL] Yes, uh, that is allowed.
[CUSTOMER][NEUTRAL] Every how often?
[AGENT][NEUTRAL] Let me look.
[CUSTOMER][NEUTRAL] And what percent is that covered up?
[AGENT][NEUTRAL] It's a maximum of 1 every 7 year period and it's limited to patients over [PII] and let me see.
[CUSTOMER][NEUTRAL] Are you still able to just send me, go ahead and send me the fax back?
[AGENT][POSITIVE] Yes, I can do that because I'm having to go back and forth trying to find it for you.
[CUSTOMER][NEUTRAL] And then if you're able to just give me history then I'll get the rest of the fax back.
[AGENT][NEUTRAL] Alright, let me go
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me get the fax back ready for you.
[AGENT][NEUTRAL] Alright, and what's a good fax number for you?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And I could provide you with the procedure codes that I need history for.
[AGENT][NEUTRAL] OK, give me just one moment so I can send this fax back to you.
[AGENT][NEUTRAL] And do you want attention to you?
[CUSTOMER][POSITIVE] It comes directly into the front office you don't need to put attention to anybody.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And to confirm, I have [PII], correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, I just sent that over.
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][NEUTRAL] OK, what is the first procedure code?
[CUSTOMER][NEUTRAL] D 0210.
[AGENT][NEUTRAL] Uh, is it intraoral X-rays?
[CUSTOMER][NEUTRAL] The full mouth X-rays?
[AGENT][NEUTRAL] OK, um, it looks like the last one they had done was in [PII].
[CUSTOMER][NEUTRAL] I need an exact date because it's due to frequency, right? And if I could get frequency for it as well.
[AGENT][NEUTRAL] Oh, it looks like [PII].
[CUSTOMER][NEUTRAL] And that's covered every how often?
[AGENT][NEUTRAL] Uh, once every 5 years.
[CUSTOMER][NEUTRAL] Does the share frequency with panel D0330?
[AGENT][NEUTRAL] What was it? 0330?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, it looks like that was done.
[AGENT][NEUTRAL] On [PII].
[CUSTOMER][NEUTRAL] And that's covered every 5 years as well?
[AGENT][NEUTRAL] Um, if it's full mouth X-ray and panoramics, yes, those are once every 5 years.
[CUSTOMER][NEUTRAL] And they share frequency?
[AGENT][NEUTRAL] Yes, once every 5 years.
[CUSTOMER][NEUTRAL] Do they share frequency? Like can we build one or the other? Does it interfere if we build for a panel and they have history of FMX?
[AGENT][NEUTRAL] Oh, OK, let me see.
[AGENT][NEUTRAL] It's limited to one X-ray procedure per 5-year period.
[CUSTOMER][NEUTRAL] No I don't think you're understanding my question. Is there somebody that can help me with the breakdown of benefits? Because I, I have a lot of questions in regards to frequency.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] It would be me and I
[AGENT][NEUTRAL] Did I not answer it right? I just.
[CUSTOMER][NEUTRAL] Are you just not familiar with how the insurance works or?
[AGENT][NEUTRAL] It would just be one or the other per 5 year period, so just one procedure.
[CUSTOMER][NEUTRAL] You gave me history for the both procedures, so do they not share frequency is my question.
[AGENT][NEUTRAL] Let me check for you. Just give me 1 2nd.
[CUSTOMER][NEUTRAL] Because if one was done in [PII] and the other one was [PII], to me they don't share frequency, but I really wanted to get your OK and and.
[AGENT][NEUTRAL] Um, well, we didn't pay for that 2nd 1.
[CUSTOMER][NEUTRAL] You know, but
[CUSTOMER][NEUTRAL] So yes, um, bite wings.
[CUSTOMER][NEUTRAL] 0274.
[AGENT][NEUTRAL] I see.
[AGENT][NEUTRAL] 0274.
[AGENT][NEUTRAL] It looks like that happened on [PII].
[CUSTOMER][NEUTRAL] And then as well if I could know how often those are covered.
[AGENT][NEUTRAL] Uh, once every 12 or once per 12 month period.
[CUSTOMER][NEUTRAL] And then any history for 4341?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] 3341, let me look.
[AGENT][NEUTRAL] I'm not showing any history for 4341.
[CUSTOMER][POSITIVE] OK, thank you.