AccountId: 011433970860
ContactId: cd62bd59-ce90-45b7-80bc-c98cccfd0960
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 503989 ms
Total Talk Time (AGENT): 162657 ms
Total Talk Time (CUSTOMER): 317946 ms
Interruptions: 9
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/08/cd62bd59-ce90-45b7-80bc-c98cccfd0960_20250108T20:12_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Uh, hey, [PII]. This is uh [PII] calling from the provider's office to check the eligibility of the patient. Can you please help me out with that?
[AGENT][NEUTRAL] I can help you spell your name for me?
[CUSTOMER][NEUTRAL] Uh, it's uh [PII].
[AGENT][NEUTRAL] And you're wanting to check eligibility?
[CUSTOMER][NEUTRAL] That is.
[CUSTOMER][NEUTRAL] Yes, right.
[AGENT][NEUTRAL] And what's the policy number, [PII]?
[CUSTOMER][NEUTRAL] Uh, it's 02510234.
[AGENT][NEUTRAL] And what's a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] The callback number, it's [PII].
[AGENT][POSITIVE] Thank you, give me one moment to pull up the file.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] To
[CUSTOMER][NEUTRAL] Yeah what's wrong in there.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh, patient's name is uh [PII] with the date of birth of [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And
[AGENT][POSITIVE] Thank you for that.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And I have the eligibility information ready. I'm showing an effective date of [PII], and I show the policy is active at this time. And did you have any other questions, [PII]?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] A day.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes. Uh, so can you please confirm the policyholder, is it uh [PII] with the date of birth of uh [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Can, can you also help uh help me with the patient's group number and group name?
[AGENT][NEUTRAL] Group number?
[AGENT][NEUTRAL] It's 70,030 group name Creative circle.
[AGENT][NEUTRAL] LLC.
[CUSTOMER][NEUTRAL] Creative
[CUSTOMER][NEUTRAL] Creative Circle LLC. OK, and the coinsurance, it's uh 180 and 50 for the preventive basic and uh service, right?
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, so are you wanting benefit information as well?
[CUSTOMER][NEUTRAL] Yes, right.
[AGENT][NEUTRAL] Under this policy, it just covers preventive and basic, preventive 100% basic at 80. No major is covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Thank you for that. And so, uh, what about the coordination of benefits for this patient's plan?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, the coordination of benefits, is it as standard, the COB?
[AGENT][NEUTRAL] Standard COB.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] OK, and, uh, is there any missing class or waiting on this patient's plan?
[AGENT][NEUTRAL] There is, and I can fax you over the schedule of benefits, [PII], if you would like.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Actually, I have the fastback of benefits and it is showing that there is a missing tooth clause. So uh what will be the duration of the missing tooth clause?
[AGENT][NEUTRAL] Yeah, I know there's no major so you can just disregard that.
[CUSTOMER][NEUTRAL] Uh, OK, so, so, uh, missing tooth class cannot be considered.
[AGENT][NEUTRAL] Major
[AGENT][NEUTRAL] Yeah, his major isn't covered. There's only one extraction code.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Um, but there's no major services, so.
[CUSTOMER][NEUTRAL] Uh, OK. Um, thank you for that, and so, and there is no waiting period on this patient plan, right?
[AGENT][NEUTRAL] On the schedule there shouldn't be a waiting period because there's no major.
[CUSTOMER][NEUTRAL] there should be like because they're.
[CUSTOMER][NEUTRAL] Uh, OK. Yes, and there is no major service available in this, uh, so, um, so, uh, so just to confirm, the major service it's, uh, not at all covered on this patient plan, right? It is not due to the age limitation, uh, I'm sorry, it's not to the due to the waiting period, right?
[AGENT][NEUTRAL] You have the schedule in front of you?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, so you're looking at the schedule of benefits for the patient. Major is not covered based on the the patient's policy.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. Um, thank you for that. And so does the plan for any kind of uh pre-authorization?
[AGENT][NEUTRAL] Prior authorization or predetermination is not required.
[CUSTOMER][NEUTRAL] Oh, OK, um, thank you for that. And that's the maximum of this plan is the place to which your services.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] The max applies to, uh, uh, does it applies to, uh, the preventive and basic service or, or only to the basic service?
[AGENT][NEUTRAL] You mean the calendar your maximum?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, that includes any service provided.
[CUSTOMER][NEUTRAL] Uh, OK. Thank you for that. And so, uh, also it's, uh, not a covered benefits on this patient's plan, right?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, orthodontics, it's, uh, not a, uh, covered benefits on this patient's plan, right?
[AGENT][NEUTRAL] Yeah, and the common exclusions it says orthodontic treatment is not covered.
[CUSTOMER][NEUTRAL] OK, um, thank you for that. And so may I also know the remaining for the patient's individual maximum and deductibles, please.
[AGENT][NEUTRAL] It's 500, no claims are on file for this patient at this time.
[CUSTOMER][NEUTRAL] OK, so nothing has been met from the maximum and deductibles, right?
[AGENT][NEUTRAL] There are no claims on file for this patient, so no benefits have been paid at this time.
[CUSTOMER][NEUTRAL] OK. Uh, thank you for that. And so just to confirm the, uh, so the procedure codes which is not available on the faxback are not uh covered service, right?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] The procedure codes which is not available on the fax back, is not a covered service, right?
[AGENT][NEUTRAL] If you do not see the procedure code on that schedule, that means it's not covered. Correct.
[CUSTOMER][NEUTRAL] Somebody
[CUSTOMER][NEUTRAL] OK. Thank you for that. And so, uh, are the in and out of network benefits, are they, are they the same on this patient's plan?
[AGENT][NEUTRAL] So if you're part of the the caring to network it could afford the patient a discount. If you're not, you'll still receive a benefit but not at a discounted rate.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, OK, so are they, uh, are the benefits, uh, different for the out of network? It's the same, OK. And, uh, does the patient has any history on file which affects the frequency?
[AGENT][NEUTRAL] It's the same.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There are no claims on file for this patient at this time.
[CUSTOMER][NEUTRAL] OK, thank you for that. And so, so, uh, is the full rate code 1206 and 1208 covered on this member's plan?
[AGENT][NEUTRAL] OK. Do you have a copy of the schedule in front of you, [PII]?
[CUSTOMER][NEUTRAL] I think that in the
[CUSTOMER][NEUTRAL] Yes, OK, thank you for that. And, uh, so for the code 9110, does it require any clinical narrative?
[AGENT][NEUTRAL] OK, so if the code is not listed on that schedule, it's not covered?
[AGENT][NEUTRAL] OK, I didn't understand. Repeat, please.
[CUSTOMER][NEUTRAL] The code 9110. Does it require any clinical narrative or any documentation from the provider?
[AGENT][NEUTRAL] There it doesn't indicate it by that code. There's no um.
[CUSTOMER][NEUTRAL] There it isn't indicated by that.
[AGENT][NEUTRAL] Exceptions or limitations on that code?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, um, thank you for that. And, uh, so can you also help me with the fee schedule follow on this plan?
[AGENT][NEUTRAL] OK, so it's based.
[CUSTOMER][NEUTRAL] It
[AGENT][POSITIVE] It's reimbursed at 100% of allowable for preventive and 80% of allowable for basic.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. And uh what about the fee schedule follow on the patient's plan? That's the co-insurance, right? Yeah.
[AGENT][NEUTRAL] So there's not a particular amount per code. It's based, if it's preventive, it's reimbursed at 100% of allowable. If it's basic it's reimbursed at 80% of allowable.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] OK, OK. Thank you for that. And so, so in that case, that will be all. Uh, thank you so much for helping me out today. So, uh, I'm so sorry. Uh, uh, OK, so that will be all. So can you please spell your name for me along with the reference number for this call?
[AGENT][NEUTRAL] You'll use my name in today's date as your reference, [PII] First initial of my last name is [PII] and any information provided today is verification only, not a guarantee of payments, [PII]. And did you have any other questions I can help out with today?
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] No, that will be all. Thank you so much for that and have a great day.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] You're welcome thanks for calling APL have a good day.
[CUSTOMER][POSITIVE] Yeah, take care, bye-bye.