AccountId: 011433970860
ContactId: cf666437-ddb2-40b8-a78a-5b02942c1114
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 644000 ms
Total Talk Time (AGENT): 287116 ms
Total Talk Time (CUSTOMER): 213053 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/11/cf666437-ddb2-40b8-a78a-5b02942c1114_20250311T20:28_UTC.wav
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[AGENT][NEUTRAL] This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] in customer services. How are you?
[AGENT][POSITIVE] Pretty good. How are you?
[CUSTOMER][NEUTRAL] I'm good. I have a provider on the phone needing um a breakdown of benefits.
[AGENT][POSITIVE] Yes, I can certainly help with that. What is the policy number?
[CUSTOMER][NEUTRAL] OK, the policy number is 258.
[CUSTOMER][NEUTRAL] 8018
[CUSTOMER][NEUTRAL] On aio Margolis.
[AGENT][POSITIVE] I go, yeah, sure. I can certainly help with that.
[CUSTOMER][NEUTRAL] And the lady on the phone is [PII], and do you need her callback number?
[AGENT][NEUTRAL] Um, does it end in [PII]?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, what is it?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Great. OK. Yes, so, um, I'm sorry, [PII], yes, I can certainly help her.
[CUSTOMER][POSITIVE] All right thank you [PII] and here she is.
[AGENT][POSITIVE] OK, thanks.
[AGENT][NEUTRAL] My name, my name is [PII]. I'm in the claims department. Um, I have pulled up the Margalis's, uh, policy, and I understand that you wanted to know about the eligibility and benefits. Is that correct?
[CUSTOMER][NEUTRAL] Uh, yes, I wanted to get a breakdown of the benefits for the patient.
[AGENT][NEUTRAL] OK, I can help with that. Um, first of all, the policy went into effect on [PII], uh, uh, I, I forgive me, I'm sorry, it's the way that these things are written. [PII], it is, uh, active. Now, um, these policies have $500 per calendar year as a maximum. That's just a verification, the benefit is not a guarantee of payment and what it covers is basic, basic restorative and preventative services only.
[AGENT][NEUTRAL] Um, so it will cover like 2 cleanings a year, 2 examinations, the filming of the teeth, that sort of thing. It's just that it doesn't cover endodontics, periodontal services, um, anything like that. Now, if, if you would like, I can send you a copy of this policy, or is there anything in particular that I could help with?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Well I mean if it's that limited, so like when you say exam just the 0 120 or does that include the 0140 and the 0 150?
[AGENT][NEUTRAL] Yes, yes, it does. Any of the exams, it's 2 per calendar year.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] So they all share then.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then um for.
[CUSTOMER][NEUTRAL] The pro fee is the child pro fee covered or is it just the adult pro fee?
[AGENT][NEUTRAL] Uh, the, uh, profy for the children is covered as well. It's also 2 per calendar year or once every 6 months, I should say.
[CUSTOMER][NEUTRAL] And does it have an age limitation then for it?
[AGENT][NEUTRAL] Uh, no, um, they age out of the program at [PII], but that's, you know, beyond that, there's no limitation.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, would the fluoride and ceilings be covered?
[AGENT][NEUTRAL] Yes, the fluoride and sealants, um, that is covered uh for patients [PII] and under. Um, so for the, uh, fluoride, um, that is uh covered, uh, at, um, it's one procedure for 12 months, and that is for the dependent children [PII] and under, and then the sealants, uh, that is, um,
[AGENT][NEUTRAL] Excuse me here. Uh, that is covered at, uh, um, a maximum maximum procedure once every 36 months. Um, that is limited to, uh, the permanent molars only and it's dependent children [PII] and under.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then um will there be coverage for like um the FMX, the pano by wing?
[AGENT][NEUTRAL] Yes, the uh bite wings are covered. Um, that is once every 12 months, and the full mouth and panel are once every 5.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] That's every 5, OK.
[AGENT][NEUTRAL] I, I don't show any history uh for, for [PII] um or for her family, so it's, it's all going to um be available.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what about PAs are they covered service?
[AGENT][NEUTRAL] Uh, is there a particular, um, uh,
[CUSTOMER][NEUTRAL] Uh, it's [PII].
[AGENT][NEUTRAL] Code that you can give me?
[AGENT][POSITIVE] Uh, yes, that is covered. That is correct.
[CUSTOMER][NEUTRAL] OK, do they have a frequency then?
[AGENT][NEUTRAL] And that
[AGENT][NEGATIVE] Uh, see, no, it does not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Would the 4346 and the 4910 be covered because they will sometimes share with the pro fee?
[AGENT][NEGATIVE] No, those are not covered.
[CUSTOMER][NEUTRAL] OK, what about um a 0364 0367?
[AGENT][NEUTRAL] Let's see, uh,
[AGENT][NEGATIVE] That is not covered.
[CUSTOMER][NEUTRAL] OK, and the 9310?
[AGENT][NEUTRAL] That is covered under uh basic, that's at 80%, but that is covered.
[CUSTOMER][NEUTRAL] OK, so that would be 80%. OK, does it have a frequency?
[AGENT][NEGATIVE] Uh, no, it does not.
[CUSTOMER][NEUTRAL] Will that share with the like the regular exam?
[AGENT][NEUTRAL] It, it, uh, uh, I'm not really, it doesn't show any, any frequency at all, so it probably does share with the regular exams, but there is no frequency that is listed on this policy.
[CUSTOMER][POSITIVE] Be pretty OK.
[CUSTOMER][NEUTRAL] And then um would the composites be covered the 2391 2330?
[AGENT][POSITIVE] They are covered, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do they have a frequency then?
[AGENT][NEUTRAL] Yes, the, uh, let's see.
[AGENT][NEUTRAL] Right, that is uh
[AGENT][NEUTRAL] A maximum of 1 each tooth for 24 months, that's replaced existing only in place for 24 months.
[CUSTOMER][NEUTRAL] OK, does that downgrade or is it pay at a white?
[AGENT][NEGATIVE] It does not downgrade, no.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright and then.
[CUSTOMER][NEUTRAL] Let's finish putting this
[CUSTOMER][NEUTRAL] Now for this policy, um, do we have to bill it first before we bill her regular insurance?
[AGENT][NEUTRAL] No, no, you can just.
[CUSTOMER][NEUTRAL] Or does it not matter?
[AGENT][NEUTRAL] It doesn't matter. We don't, there's no coordination of benefits, so uh.
[CUSTOMER][NEGATIVE] So it doesn't coordinate at all.
[AGENT][NEGATIVE] No, it does not.
[CUSTOMER][NEUTRAL] OK, um, will it accept assignment of benefits?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um, and then.
[CUSTOMER][NEUTRAL] See.
[CUSTOMER][NEUTRAL] Any um
[CUSTOMER][NEUTRAL] Deductibles on the policy at all?
[AGENT][NEUTRAL] There is a $50 deductible that does not apply to preventative services.
[CUSTOMER][NEUTRAL] OK, just the basic services?
[AGENT][POSITIVE] That's correct, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Is my office showing in network for the policy or my doctor?
[AGENT][NEUTRAL] We don't actually have a, a network. Um, the, the policy, yeah, because it is a limited benefit policy, there is no network.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so then it pays that what um UCR maximum allowable?
[AGENT][NEUTRAL] What it does is we follow the Carrington PPO fee schedule on this, on this policy.
[AGENT][NEUTRAL] So it's, it just pays a percentage of that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and I know we're not in network with Carrington, um, so the preventative and diagnostic are at 100.
[AGENT][NEUTRAL] Oh, you don't have to be. That's.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And, and the basic and basic restorative are at 80%.
[CUSTOMER][NEUTRAL] Then obviously there's no missing two clauses because there's no major services so let's not. What about any waiting periods on the policy?
[AGENT][NEUTRAL] Uh, there's no waiting periods.
[CUSTOMER][NEUTRAL] OK, you said it was a PPO plan?
[AGENT][NEUTRAL] Uh, no, no, it's not a PPO plan. The, the policy, it just, um, there isn't a PPO plan. It's just, uh, what it does is it just, it just pays that percentage of, of, um, of what, uh.
[AGENT][NEUTRAL] Of what it is a portion of the Carrington er services, so there's no PPO plan on here.
[CUSTOMER][NEUTRAL] OK, and it is a calendar year plan then?
[AGENT][NEUTRAL] It is, yes.
[CUSTOMER][NEUTRAL] It is
[CUSTOMER][NEUTRAL] You said she has no history on file?
[AGENT][NEUTRAL] No history, no.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, and then can I get the claim address and payer ID?
[AGENT][NEUTRAL] It's our payer ID is 60801.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And our address is [PII].
[AGENT][NEUTRAL] That is in [PII].
[AGENT][NEUTRAL] And our
[AGENT][NEUTRAL] The code
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And let me just see where I'm at here.
[CUSTOMER][NEUTRAL] You said you had no history on file, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] And not use any of the annual max?
[AGENT][NEGATIVE] No, nothing's been used so far.
[CUSTOMER][POSITIVE] OK awesome and then is there a direct number because I got transferred a couple of times.
[AGENT][NEUTRAL] Oh, yes, it's um it's uh [PII].
[AGENT][NEUTRAL] [PII] and we're extension 2.
[CUSTOMER][NEUTRAL] [PII] OK and then I'm sorry, you said your name was?
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] [PII], OK, and is there a reference number [PII]?
[AGENT][NEUTRAL] Yes, it's my name and today's date.
[CUSTOMER][POSITIVE] OK awesome well thank you very much.
[AGENT][NEUTRAL] Is there anything else that I can help with?
[CUSTOMER][NEUTRAL] No, that's all I needed.
[AGENT][NEUTRAL] Is it
[AGENT][POSITIVE] OK, well thank you for contacting ATL have a very good day.