AccountId: 011433970860
ContactId: cdde750b-1362-48bd-bdc9-4574c125eb12
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 632479 ms
Total Talk Time (AGENT): 219368 ms
Total Talk Time (CUSTOMER): 282313 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/09/cdde750b-1362-48bd-bdc9-4574c125eb12_20250409T19:06_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is. How may I assist you?
[CUSTOMER][POSITIVE] Thank you for calling.
[CUSTOMER][NEUTRAL] Hi, this is [PII]. I'm calling from a provider's office. I just want to check benefits and eligibility for a patient, please.
[AGENT][NEUTRAL] OK. Did you say [PII] or [PII]?
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][POSITIVE] [PII], thank you.
[AGENT][NEUTRAL] And may I please have a call back number and then the policy number?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Uh, callback number is the one that I'm using right now, [PII], no um extension, and the policy number, it is 2363602.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] This is for patient [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] And that's 02363602?
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] 360
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] I don't have a member by that name under this policy.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, so, uh, the member ID worked, but the patient name does not match any, um, on their own that policy, is that correct?
[AGENT][NEUTRAL] Could you spell the member's first and last name for me?
[CUSTOMER][NEUTRAL] Oh, for sure. First name is [PII].
[CUSTOMER][NEUTRAL] And last name is [PII].
[AGENT][NEUTRAL] May I have the date of birth?
[CUSTOMER][NEUTRAL] Yeah, date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] So the correct policy number is 02.
[CUSTOMER][NEUTRAL] So they.
[AGENT][NEUTRAL] 36
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 3607.
[CUSTOMER][NEUTRAL] 3
[CUSTOMER][NEUTRAL] 007.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much for that.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And you're calling in for eligibility and benefits for this member?
[CUSTOMER][NEUTRAL] In your policy
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, would you like a fax back for this member?
[CUSTOMER][POSITIVE] That's gonna be very helpful, yes, please, and on that fax part I just wanna confirm I'll be able to see the frequencies there, right?
[AGENT][NEUTRAL] Mhm. Yeah.
[AGENT][NEUTRAL] Yes, if there's any frequencies or if there's any tooth cloth, anything that it needs to be listed, let me pull this image up for you, the benefits for you.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Alright, that's wonderful.
[CUSTOMER][POSITIVE] Yeah, um, if you can do me a fax back that's gonna be very wonderful.
[AGENT][NEUTRAL] OK, now may I have a fax number to submit that to you?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Of course, fax number will be [PII].
[AGENT][NEUTRAL] And it will show the effective date, but I can go ahead and give that to you. This policy is currently active with the effective date of [PII]. Is there anything else that I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Of course.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh yeah, um, since I've got you on the line I just wanna verify, are we in the network with this plan?
[AGENT][NEUTRAL] So with this policy, it does not, um, it doesn't have to be in or out of network.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 00 it's open access, OK um.
[CUSTOMER][NEUTRAL] What about the fee schedule? Do we follow the Carrington fee schedule?
[AGENT][NEUTRAL] Now you can check to see if if it doesn't say that this is for Carrington but you are more than welcome to contact Carrington to see if this member is listed for them but for the fee schedule you would use with the for the providers within that area, whatever fee schedule it is when that area is of UCR.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] It doesn't get you.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] He's here. All right, no problem. Take note of that. And also I would like to verify um if there are downgrades for fillings and crowns on this plan or do you guys downgrade?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] No downgrade.
[CUSTOMER][NEUTRAL] No downgrades. Uh, hold on, thank you. For SRPs, how many questions do we allow per visit?
[AGENT][NEUTRAL] For which one?
[CUSTOMER][NEUTRAL] 4341.
[AGENT][NEUTRAL] Let me check that for you.
[CUSTOMER][POSITIVE] For SRP thank you.
[AGENT][NEUTRAL] It says for that one it's a maximum of 1 each quadrant per 24 months and that limitation is also listed at the bottom of that fee of that schedule or benefits.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so, alright, so we allow all 4 quadrants the same visit.
[AGENT][NEUTRAL] A maximum of 1 each quadrant per 24 months.
[CUSTOMER][NEUTRAL] OK, one.
[CUSTOMER][NEUTRAL] No, uh, what I'm asking about is per visit, uh, are we allowed?
[CUSTOMER][NEUTRAL] Like, are we allowed for all 4 quadrants or just really one per visit for 24 months?
[AGENT][NEUTRAL] So if it's one quadrant, one each.
[AGENT][NEUTRAL] Each quadrant per 24 months, so that's a maximum of 1 each, that each quadrant one.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] You, you get it, so.
[CUSTOMER][NEUTRAL] That's weird.
[AGENT][NEUTRAL] So it's explaining that you can get.
[CUSTOMER][NEUTRAL] Yeah, I am
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm, I'm, I'm getting the 24 months per quadrant, but I was, the, the, the one that I was asking about is the per visit of the patient, if you're allowed to do all four quadrants per visit.
[AGENT][NEUTRAL] Is saying each.
[AGENT][NEUTRAL] For each quadrant, each, each one.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, are we allowed to do all 4 per visit per day?
[AGENT][NEUTRAL] So the way that I'm trying to explain it is saying you can do a maximum of one each quadrant, one for each quadrant.
[CUSTOMER][NEUTRAL] Is the frequency.
[CUSTOMER][NEGATIVE] No, no, sorry.
[CUSTOMER][NEUTRAL] I'm getting the 24 months because that's the frequency, yes, uh, I know that, uh, but the question is can we do all four quadrants?
[CUSTOMER][NEUTRAL] In just a day in just one visit or because, because you're telling me the frequency only.
[AGENT][NEUTRAL] No, I'm telling you the limitations. I'm not telling you the frequency.
[CUSTOMER][NEUTRAL] But the limitation is what I'm asking.
[AGENT][NEUTRAL] I was giving you the limitation, that wasn't the frequency.
[AGENT][NEUTRAL] The limitation for that.
[CUSTOMER][NEUTRAL] OK, so we are only allowed.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For the limitation for that code that you gave, which was 04341.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] It is showing that they have a maximum of 1 each quadrant per 24 months. That's the limitation.
[CUSTOMER][NEUTRAL] So we can do all 4 quadrants per visit of the patient.
[CUSTOMER][NEUTRAL] And then they can do next after 24 months, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. So then that's the answer all 4 calls per visit. OK. And then after 4341, how long can we wait before we do the 4910? Can we do it the following day, or is there any healing period?
[AGENT][NEUTRAL] Let me see if that's in there.
[AGENT][NEUTRAL] Cause I don't believe it based, is based off of any of your, any procedure that needs to be rendered, but I will go in here and see if there's any limitations to that for you.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, with the limitations, the only thing that is giving is a maximum of 1 procedure per 6 months. So it's not saying that you can't do it within that same visit. So that's possibly the provider's discretion.
[CUSTOMER][POSITIVE] Alright thank you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it. And this probably is my last question for 9944 for a night guard or a cruisal guard, is it for boxism only?
[AGENT][NEUTRAL] May I have that code, please?
[CUSTOMER][NEUTRAL] 9944.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So for that code I'm not finding that. Let me see if we have anything.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Sure. Maybe that's not covered.
[AGENT][NEUTRAL] And it's for a night guard?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so I'm not finding that on this list, so if it's not listed on here, it's not considered covered under this policy.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK alright thank you alright I think I've got.
[CUSTOMER][POSITIVE] Everything covered in here. I'll just wait for that fax to come by. So thank you so much for your time. You have a wonderful day.
[AGENT][NEUTRAL] OK, well,
[AGENT][POSITIVE] You're welcome and thank you so much [PII] for calling American Public Life. You have a great day as well.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] Good bye, OK.
[AGENT][NEUTRAL] Bye