AccountId: 011433970860
ContactId: cb6f746c-14e6-4677-adeb-aacc3f588e3a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1367699 ms
Total Talk Time (AGENT): 744241 ms
Total Talk Time (CUSTOMER): 368749 ms
Interruptions: 4
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/03/cb6f746c-14e6-4677-adeb-aacc3f588e3a_20250403T17:14_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, um, I have a question, um.
[CUSTOMER][NEUTRAL] I had uh a dentist appointment for my son and um
[CUSTOMER][NEUTRAL] I was trying to see if, if they have to extract like a wisdom tooth. Is that covered up under?
[CUSTOMER][NEUTRAL] Um, our dental insurance?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Well, I, it would be my pleasure to assist you with those benefits. What is a good callback number just in case we get disconnected, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] All right, thank you. And do you have your dental policy certificate number available?
[CUSTOMER][NEUTRAL] Yes, it is.
[CUSTOMER][NEUTRAL] 02574708
[AGENT][NEUTRAL] Thank you. And what is your name and date of birth, please, ma'am?
[CUSTOMER][NEUTRAL] [PII], [PII] and [PII].
[AGENT][NEUTRAL] Thank you, Ms. [PII]. And do you, uh, Ms. [PII], do you mind verifying your current mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] Now you've been south of all those storms coming in, haven't you? Aren't you?
[CUSTOMER][NEUTRAL] Yeah, we've been out of the way of them, um, just getting a lot of wind.
[AGENT][POSITIVE] That's good.
[AGENT][NEUTRAL] Uh, it's just been, I'm down around the [PII] area and it's been so windy.
[AGENT][NEUTRAL] But I'm just glad all those bad storms are not happening around you.
[CUSTOMER][NEUTRAL] Oh yeah.
[AGENT][NEGATIVE] It's been rough.
[CUSTOMER][POSITIVE] Yes, I'm glad too.
[AGENT][NEUTRAL] Absolutely. Let's see, so I've got your policy pulled up and you're wanting to know if a wisdom tooth extraction is covered for one of your children dependents. Is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Right. That's correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So it depends on the type of extraction. Are they wanting him to see an oral surgeon, surgeon?
[CUSTOMER][NEUTRAL] That's what they um mentioned.
[AGENT][NEUTRAL] OK, now the policy I'm showing that you all have the active dental policy that's active since [PII]. Now, oral surgery is considered a major procedure, and there is a 12 month waiting period for major procedures to be covered.
[AGENT][NEUTRAL] So as of right now, the oral surgery would not be covered until [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There is a simple extraction that is covered under basic services, which is covered now without that 12 month waiting period. But it seems that most of the time with wisdom teeth, they do like to go through an oral surgeon for that.
[CUSTOMER][NEUTRAL] Mhm. So with the basic extraction, that means that the tooth is already out of the gum, correct?
[AGENT][NEUTRAL] Right. Mhm. And they just pull the tooth.
[AGENT][NEUTRAL] No surgery involved.
[CUSTOMER][NEUTRAL] OK, so that will be covered but just not the one that's in the gum.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Let me ask you this, like, um, like I noticed too, like mostly, most um dentists and oral surgeons in my area, um, they do not accept American public life.
[AGENT][NEUTRAL] Have they told you why?
[CUSTOMER][NEUTRAL] Um, they just, well, no, they just, they haven't explained why, but they just.
[AGENT][NEUTRAL] I, I'm curious as to why because this is.
[CUSTOMER][NEUTRAL] Well it's like, it's.
[CUSTOMER][NEUTRAL] It, it's like, it's like.
[CUSTOMER][NEUTRAL] Like, like, OK, say for instance I just left the dentist and um they um called an oral surgeon's office and they was like um they didn't accept that particular insurance.
[CUSTOMER][NEUTRAL] And um they called actually two of them and so she told me to ask.
[AGENT][POSITIVE] I'm really nice.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. She told me to ask, um, do you all have a an oral surgeon that you all with?
[CUSTOMER][POSITIVE] You know that that's approved with you all.
[AGENT][NEUTRAL] So here's the the um.
[AGENT][POSITIVE] Here's the it's in in this great feature on this policy we do not participate in any network.
[AGENT][NEUTRAL] So, and because, you know, your husband may be out on the road and there may not be any dental providers in a certain network.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] In, you know,
[AGENT][NEUTRAL] [PII] or whatever, you know.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, right.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So therefore this policy does not participate in a network so he could go or his family could go to any dental provider. There's no network. If they ask, now we do pay at a percentage of UCR UCR stands for usual customary rate.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] So whatever the usual rate is in that area, then we would pay according to the policy guidelines that that percentage. So for example, your preventive is covered at 100%.
[AGENT][NEUTRAL] And then your basic procedures and your x-rays, all that is covered at 80% of the usual rate in that area. And then your major procedures after that 12 month waiting period has been satisfied, is covered at 40% of the usual customary rate.
[AGENT][NEUTRAL] In that area for that dental provider. So there's actually, I'm not understanding why they're saying they don't accept it. You know, a lot of times these providers that they would just call us, you know, and, and there's so many insurances out there.
[AGENT][NEGATIVE] You know, they probably just didn't wanna, I mean, I'm not gonna say this out loud, but I'm gonna tell you that they probably didn't wanna call us to you know take the time to call.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And see what type of coverage it is. But I didn't say that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I got you. I got you. Let me, let me see, um, that I had to ask, um.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] So basically anything as long as it's not a surgery is covered now, but if it has to be a surgery, it's a 12 month period.
[AGENT][POSITIVE] That's right. And after that, um, 12 month period has been satisfied. Now, that includes things like oral surgery, crowns, bridges, root canals.
[AGENT][NEUTRAL] That is all considered and, you know, the extensive gum treatment, that's considered a major procedure. So any endodontic services or periodontic services is included in major.
[AGENT][NEUTRAL] So, as of right now, for your fillings, your extensive X-rays, your um problem visits, that's all considered basic.
[AGENT][NEUTRAL] And actually we do have a website if you ever want to create a login and password on our portal, it would have to be your husband's information um he can create an account and you can click on the policy number and it will show you everything that's covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, let me ask you this. I know you said like uh preventive is covered at 100%, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well, I, he just got my son, he just got a cleaning and I had to pay like $90 something dollars.
[AGENT][NEUTRAL] You had to pay 90
[AGENT][NEUTRAL] I'm sorry, you have to pay $90?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So did that [PII] not accept our uh policy?
[CUSTOMER][NEUTRAL] I did.
[CUSTOMER][NEUTRAL] Um, they said they did, but I guess at the rate that you all, you all have for cleaning, what's your rate for cleaning?
[AGENT][NEUTRAL] They say that we
[AGENT][NEUTRAL] So it, it would pay 100% if they're in the usual uh customer rate in your area.
[AGENT][NEUTRAL] So in order to look that up I would have to have that procedure code and the zip code for the general provider.
[CUSTOMER][NEUTRAL] OK, let me see uh.
[CUSTOMER][NEUTRAL] Let's see, I just got a description. I don't see a code. Um, it's a comprehensive or evaluation.
[AGENT][NEUTRAL] OK. Let's see what I can find out.
[CUSTOMER][POSITIVE] In a panoramic form.
[AGENT][NEUTRAL] Now the pano is considered basic under basic procedures so we would only pay 80% of that so I'm wondering if they calculated that let's.
[AGENT][NEUTRAL] Hang on just a second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let's see if I can figure that out for you.
[AGENT][NEUTRAL] Kind of get you an idea and also just to know.
[AGENT][NEUTRAL] That if you ever have to pay for something you can send us an itemized bill.
[AGENT][NEUTRAL] With that
[AGENT][NEUTRAL] The codes and charges and we can reimburse you.
[AGENT][NEUTRAL] Or it would go to Mr. [PII].
[AGENT][NEUTRAL] The reimbursement would.
[CUSTOMER][NEUTRAL] So is it too late now, or I need to do it prior or after?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It would be after the services are performed, but you can definitely, if you have a a list of all the service, the service codes that would be the um procedure codes and the charges.
[AGENT][NEUTRAL] You can actually upload that claim directly on the policy online.
[CUSTOMER][NEUTRAL] So, so if I don't have the code but I have the description, would that be?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] Um, let's see, hang on just a second. You said it was a comprehensive event exam?
[CUSTOMER][NEUTRAL] Yes, like it's like I have a description of the services that were provided, but I don't see a number like for a code. It says comprehensive oral evaluation, then it's got the panoramic film and the Lexus.
[AGENT][NEUTRAL] Prophylaxis, that's the cleaning.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And do you have the zip code?
[CUSTOMER][NEUTRAL] OK, and then I see.
[AGENT][NEUTRAL] For the general provider?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 3
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Let me just check something real quick.
[AGENT][NEUTRAL] So for um the usual customary rate in that area is 160 for that panoramic radiographic service. I don't know what they charged.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] They charged 130.
[AGENT][NEUTRAL] OK, so see we would pay all of that.
[AGENT][NEUTRAL] Can you call that dental provider back and just ask them to give you um something if they're not gonna submit let's see what else did it have the prophylaxis?
[CUSTOMER][NEUTRAL] It's got, uh, yeah, prophylaxis is $82.
[AGENT][NEUTRAL] OK, so they did charge over it's the normal, well, let's see that's Lake Charles, hang on, is this?
[AGENT][NEUTRAL] In [PII], you said.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 397-005
[AGENT][NEGATIVE] I might have given you a wrong thing. Hang on.
[AGENT][NEUTRAL] Oh, that's better. [PII] and I'll have to recheck that other one. yeah, the, how much did they charge for the prophy? They, they call it a prophy for short.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, it's $82.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] And the usual rate is around 74, so it doesn't mean that they're overcharging, it just means for that entire area the average charge, and that's what we pay is 74.
[AGENT][NEUTRAL] And let me go back to the comprehensive.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I see.
[AGENT][NEUTRAL] Because
[AGENT][NEUTRAL] So it might have just been that difference if there was a difference in what we would pay and what they charged that they might have charged you for. It looks like 113 is for the oral evaluation.
[CUSTOMER][NEUTRAL] And that they charged me 92, so.
[AGENT][NEUTRAL] So that would have been covered at 100%.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then the panoramic. Let's check that. I think we already did though.
[CUSTOMER][NEUTRAL] What?
[AGENT][NEUTRAL] It's just the the charges this doesn't mean like I said that they're charging over what they should be charging, but whatever they charge if it is.
[AGENT][NEUTRAL] Less than the usual customer I mean we're gonna cover it at 100%. So example, if you go in for a cleaning and so let's just say that they charge $75.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] If the usual rate is $50 in that area, we're only gonna pay 100% of that usual rate, which is $50.
[AGENT][NEUTRAL] Meaning that you would be responsible for the remaining 25.
[AGENT][NEUTRAL] If it is less than we're still gonna pay 100%.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I'm not sure you did, I'm not sure why they charged you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, just make sure to see if they are going to file a claim with us. If they say no, then ask them for an itemized bill with the procedures listed, and then you can upload that claim on online on our portal if you create that, or you can fax it to us.
[AGENT][NEUTRAL] And then we can process that.
[CUSTOMER][NEUTRAL] OK, so
[AGENT][NEUTRAL] And pay you
[CUSTOMER][NEUTRAL] So you, so do you need, you need the code or you can go off the description?
[AGENT][NEUTRAL] We really need the codes.
[CUSTOMER][NEUTRAL] I have a receipt.
[AGENT][NEUTRAL] Because sometimes there are 2 codes, if it's not, for example, for bite wings, which is an X-ray, you've got the single film, 2 films, 4 films, and the codes are all different.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So we really need the codes.
[AGENT][NEUTRAL] Maybe they can email it to you or something.
[CUSTOMER][NEUTRAL] OK, so I need to go back.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Now, if, if
[CUSTOMER][NEUTRAL] I can ask him.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I'm still at the dentist. I haven't left. I'm just not inside. I'm outside.
[AGENT][NEUTRAL] Oh, are you?
[AGENT][NEUTRAL] Oh, got you. Well, that's good. So I would ask them if they're going to file with us and if you wanna go back in for that oral surgeon and let them know that there's no network. We pay to by UCR they can call us. We'll be happy to verify the benefits and um that might help them with the
[AGENT][NEUTRAL] Or surgery.
[AGENT][NEUTRAL] Or oral surgeon for the wisdom teeth.
[CUSTOMER][NEUTRAL] It'll have for the listing.
[AGENT][NEUTRAL] Right, for them to, like when they call to try to find someone and, you know, if they say that they don't take the insurance, then your dentist there can say, well, they pay a UCR there's no network, and that might, let me say, OK, well, we'll take it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That kind of makes sense, kind of sort of, maybe.
[CUSTOMER][NEUTRAL] It does. I think that they should have called you.
[AGENT][NEUTRAL] I do too.
[AGENT][NEUTRAL] That's what I suggest if you're ever somewhere and tell this to Mr. [PII] too if he's out on the road.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] If he has problems or you have problems, just ask them to call us so that we can give them details of the policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Or you know, ask them, please just call my insurance they can tell you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Some won't, but most will. Most are willing to help as much as they can.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] I don't see can they give me an itemized cause I look, I think they're going to lunch now.
[AGENT][NEGATIVE] Oh yeah, you better get in there and say, look, wait.
[CUSTOMER][NEUTRAL] I can see if there's someone still in there, but I think the lady that was working with me.
[CUSTOMER][NEUTRAL] She, uh, I think she's in her vehicle.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] I'll call in there and see first before I make the trip in there, but um you, OK, so if the comprehensive if it's $92 on my paper and uh you all cover that and you said if I upload it to the site that you all may reimburse us.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] And if you now we'll tell you if they decide to file a claim later, you know, sometimes it takes them a couple of days to file it if y'all uploaded on the policy we pay claims and or process claims in order that we received them so if we get the claim that's submitted by the insured or um you know by y'all.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] And then later we get the provider claim, your claim is gonna get processed first and benefits payable will come to y'all.
[AGENT][NEUTRAL] And so we won't be able to pay the provider.
[CUSTOMER][NEUTRAL] OK. I need, I'm gonna find out are they gonna um
[CUSTOMER][NEUTRAL] You know,
[AGENT][NEUTRAL] Submitted
[CUSTOMER][NEUTRAL] Send, send the claims to you. Yeah, I'll find that out too. If they're not, if they're not gonna send me anything else, then I'll um get it so you, so I can upload it.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Yeah, don't
[AGENT][NEUTRAL] And if you come across a dental provider it says we don't accept APL and you can tell them what the policy doesn't have a network they can call us, we'll be happy to verify benefits.
[CUSTOMER][NEUTRAL] OK, what, what does that stand for UCR?
[AGENT][NEUTRAL] Usual customary rate.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] They should know what it stands for.
[AGENT][NEUTRAL] Should
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I got you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, cause I gotta call her back anyway and uh tell her that if it's for oral then I'm gonna have to wait a year and you said it's only 40% covered.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] That can get kinda expensive, can't it?
[AGENT][NEUTRAL] It can. A lot of policies though on your, for your major services.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] That's
[AGENT][NEUTRAL] Basically usual for general policies for major services.
[CUSTOMER][NEUTRAL] They used to cover just 40%.
[AGENT][NEUTRAL] Usually, um, it just depends on the policy. That's, that's usually the kind of the going rate for major procedures some.
[AGENT][NEUTRAL] I think there's some policies that have 50%, but ours is 40% and I'm not sure who does have the 50% for major.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Mm.
[AGENT][NEUTRAL] But if you go online and create that um account online, you can click on the policy number and it will show you what services are covered and at what percentage.
[CUSTOMER][NEUTRAL] OK, and I just go to the [PII] and then log in to send up.
[AGENT][NEUTRAL] Yes ma'am, and you will have to use your husband's information since he's the policy holder.
[CUSTOMER][POSITIVE] Great. OK.
[CUSTOMER][NEUTRAL] OK. I'll do that.
[CUSTOMER][NEUTRAL] OK, well,
[CUSTOMER][NEUTRAL] I'm gonna, I'm, I gotta call her back and let her know about that with the oral surgery part, but then, um, and I'll find out about it, she's gonna submit a claim and if not, I need the code to submit to you all.
[AGENT][POSITIVE] That's correct.
[AGENT][POSITIVE] Well, Ms. [PII], it has been a pleasure to assist you. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, I don't think so, but if I need something else, I will be calling back.
[AGENT][POSITIVE] Absolutely. We're here to assist you any way we can.
[AGENT][NEUTRAL] And y'all stay safe with all these storms coming through.
[CUSTOMER][POSITIVE] OK, I thank you. I appreciate you.
[CUSTOMER][POSITIVE] Thank you. You too now.
[AGENT][POSITIVE] Thank you, Ms. [PII]. You take care and have a lovely day.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][POSITIVE] Thanks you too. Bye.
[AGENT][NEUTRAL] Bye bye.