AccountId: 011433970860
ContactId: cfd0b88a-55af-44c1-8f11-e96786683883
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 770450 ms
Total Talk Time (AGENT): 318334 ms
Total Talk Time (CUSTOMER): 397471 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/13/cfd0b88a-55af-44c1-8f11-e96786683883_20250313T15:57_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] Yeah, hi, this is [PII] here calling on behalf of the dental office to check eligibility and benefits for one patient today on a recorded line. So can you help me with that, please?
[AGENT][POSITIVE] [PII], it would be my pleasure to assist you. What is a good callback number?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It is going to be [PII]. And I'm so sorry, I didn't catch your name. Can you help me with your name again, please?
[AGENT][NEUTRAL] Yes, my name is [PII]
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] First initial of my last name is [PII].
[CUSTOMER][POSITIVE] Oh [PII], thank you so much.
[CUSTOMER][POSITIVE] OK, got it. Thank you so much for the confirmation of your name.
[AGENT][NEUTRAL] My pleasure, [PII]. And [PII], what is the patient's policy number?
[CUSTOMER][POSITIVE] Mhm. The patient member ID number is gonna be, just a moment, I'm so sorry.
[CUSTOMER][NEUTRAL] Yup. Uh, the patient member ID number, it is 2,457,480.
[AGENT][NEUTRAL] Thank you, [PII]. And what is the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] The patient name is going to be [PII] and then the date of birth is going to be [PII].
[AGENT][POSITIVE] All right, thank you, and it would be my pleasure to assist you with eligibility and benefits for [PII], I am showing that his policy is active.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Effective date is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this is a limited dental policy. It does not cover major procedures.
[AGENT][NEUTRAL] It does cover prevented.
[CUSTOMER][NEUTRAL] Mhm. Any major services are not covered, like, uh, crowns, bridges, dentures, implants, nothing is covered?
[AGENT][NEUTRAL] That's correct, and that does include um oral surgery, endodontic services, and periodontic services.
[CUSTOMER][NEGATIVE] They are also not covered.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Even the pay maintenance is also not covered and the SRP 4341.
[AGENT][NEUTRAL] That is not covered as well. That's correct.
[CUSTOMER][NEUTRAL] Oh my God. Oh, so there's only, only limited benefits for this one.
[AGENT][POSITIVE] That's right.
[CUSTOMER][POSITIVE] OK, [PII]. And yes, you can continue. I'm so sorry for interrupting you. I'm so sorry for that.
[AGENT][NEUTRAL] You're fine.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] And it covers your preventive and basic procedures only.
[CUSTOMER][NEUTRAL] Mhm. So, for, as you said, that uh for the basic, like, uh, even the 4910 is not covered, which generally come under the basic and the SRP is also not covered, correct?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK, and then for the posterior composite, is it downgrade on the plan?
[AGENT][NEGATIVE] We do not downgrade.
[CUSTOMER][NEUTRAL] It is not downgrade. OK, got it. And then also, is orthodontics covered in the plan?
[AGENT][NEGATIVE] It is not.
[CUSTOMER][NEUTRAL] Even orthodontics is also not covered. OK. And can you check for the code uh 2962, that one is also not downgrade. I just want to confirm like I don't want to make any mistakes from my side, that's why.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] Oh, I, I understand, not a problem. 2692?
[CUSTOMER][POSITIVE] Mhm. Thank you.
[CUSTOMER][NEUTRAL] No, no, no. 2962.
[AGENT][NEUTRAL] 2960. I thought I got it backwards thank you for verifying that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Mhm. You know, today, I do have a happy day because you're the 2nd representative, which is so good. I'm like feeling very happy to speak over the call today.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Oh.
[AGENT][POSITIVE] Well, good. It's my pleasure to assist you.
[CUSTOMER][POSITIVE] Mhm thank you.
[AGENT][NEGATIVE] Now, actually, I'm checking the the schedule, 2962 is not covered.
[CUSTOMER][NEUTRAL] Oh, OK. Got it.
[AGENT][NEUTRAL] And I actually, [PII], I have a breakdown I can fax to you that does have the list of the procedures that are covered if you're interested.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Uh, is, is it possible, [PII], like, uh, can you help me with the benefit over the call, please? It's a request from my side. I'm really happy to speak with you. That's fine.
[AGENT][NEUTRAL] We can do it.
[AGENT][NEUTRAL] I sure can.
[AGENT][POSITIVE] Not a problem. I'll be happy to do it by phone now. We'll tell you that any benefits given over the phone is a verification of coverage and not a guarantee of payment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Got it. And then, uh, can I proceed with my specific set of questions?
[AGENT][POSITIVE] Absolutely.
[CUSTOMER][NEUTRAL] OK. So can you first please help me with the group name and the group number?
[AGENT][NEUTRAL] Mhm. The group name is.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] Creative circle.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the group number?
[AGENT][NEUTRAL] Group number is 70,030.
[CUSTOMER][NEUTRAL] OK. And then [PII], like uh for this one, is this an individual plan or a family coverage plan?
[AGENT][NEUTRAL] It is an individual plan.
[CUSTOMER][NEUTRAL] A single coverage plan. And then the coordination of benefit is going to be standard or no for this one?
[AGENT][NEUTRAL] Standard.
[CUSTOMER][NEUTRAL] OK. And this is the calendar year plan?
[AGENT][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] OK. And then any waiting period or missing tooth class on the plan?
[AGENT][POSITIVE] There's no waiting period. I mean, no missing tooth cloths. Wait a minute, I'm so sorry. There is a missing tooth cloths, there is no waiting period. I'm sorry.
[CUSTOMER][NEUTRAL] Mhm. That's fine.
[CUSTOMER][NEUTRAL] OK, got it. That's fine. And then the provider is going to be in or out of network?
[AGENT][NEUTRAL] The policy participates in the Carrington PPO network, but network participation is not required for benefits.
[CUSTOMER][NEUTRAL] Oh yes.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, so basically we are in network with the Carrington. We follow the Carrington ee schedule for anthem and everything, so it will be in network. And then also, uh, a pre-authorization is mandatory, so just sit on the plan.
[AGENT][NEUTRAL] Not required.
[CUSTOMER][NEUTRAL] It is OK. And then what will be the uh age limit for dependent and student on the plan?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Got it. And then the annual max and the deductible will be?
[AGENT][NEUTRAL] The annual calendar year max is $500. There is a $50 deductible per year, and it's up to $150 per family.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] The deductible does not apply to preventive services.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And is there anything used and is the deductible being met?
[AGENT][NEGATIVE] For 2025 nothing used and deductible has not been met.
[CUSTOMER][NEUTRAL] And what will be the co-insurance for the covered service like the preventive and basic?
[AGENT][NEUTRAL] Mhm. Preventative is covered at 100%.
[AGENT][NEUTRAL] Radiographs, FMX, basic and basic restorative expenses are covered at 80%.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And 80%. Got it. Thank you. It's a 180 plan and major is not covered. And then also, uh, can you help me with the frequency for the preventative services?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure, the profies are once every 6 months.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oral evaluation is 2 for 12 month period.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And bitings are once per twelve-month period.
[CUSTOMER][NEUTRAL] And for the code 0120 is also 1 in 12 months.
[AGENT][NEUTRAL] 0120.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] One for 12 months. OK. And then 1351?
[AGENT][NEUTRAL] 1351.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, sealants that is under preventive and it's under the age of 14 and it's permanent molars only every 36 months.
[CUSTOMER][NEUTRAL] 1 in 36 months and the age [PII]. And for 1206?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, fluoride is under the age of [PII] and it's, um, every 12 months.
[CUSTOMER][NEUTRAL] Under age [PII]. OK. And then 0210?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 0210.
[AGENT][NEUTRAL] Uh, FMX andpano is once every 5 years.
[CUSTOMER][NEUTRAL] OK. And then 0460, is it covered?
[AGENT][NEUTRAL] 0460.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] It is under basic, no frequency.
[CUSTOMER][NEUTRAL] 80%. And then 4346, is it covered?
[AGENT][NEUTRAL] 4346.
[AGENT][NEGATIVE] It's not covered.
[CUSTOMER][NEUTRAL] OK. And then uh for 9222, is it covered?
[AGENT][NEUTRAL] 9222 is not covered.
[CUSTOMER][NEUTRAL] OK. And then 2643, I'm so sorry. Yes, uh 2643 is also not covered?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] 7953 is also not covered, correct?
[AGENT][POSITIVE] You're right.
[CUSTOMER][NEUTRAL] And 4263.
[AGENT][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] Same with 7956, correct?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Just more calls I want to confirm. So it is 9110, is it covered? I think that it will be covered.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It is covered under basic, no frequency.
[CUSTOMER][NEUTRAL] OK. And then 9230?
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEGATIVE] 9230 is not covered.
[CUSTOMER][NEUTRAL] And the last 1, 9944, also not covered for the fu guard.
[AGENT][NEGATIVE] Um, not covered.
[CUSTOMER][NEUTRAL] OK, got it. Thank you for that information. And then you said that there is no history, [PII], there is any history on the plant which can affect the frequency?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There is
[AGENT][NEUTRAL] There is for [PII] on [PII].
[AGENT][NEUTRAL] Uh, prophy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All exam.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then his in [PII], he had a trophy.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 213 of 24.
[AGENT][NEUTRAL] Let's see what else.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And he had bite wings and oral exam on [PII] 24.
[CUSTOMER][NEUTRAL] No history for FMX Spano.
[AGENT][NEUTRAL] No FMX or pano history.
[CUSTOMER][POSITIVE] OK, got it. Thank you. And then, just a moment.
[CUSTOMER][NEUTRAL] Or mhm. OK, [PII]. And then also, can you help me with the mailing address and then the payer ID for this one?
[AGENT][NEUTRAL] Absolutely. Our claim's mailing address is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] And the zip code, um, the payer ID is 60801.
[CUSTOMER][NEUTRAL] Got it. OK, [PII]. And then also, can you help me with the call reference number for this one?
[AGENT][NEUTRAL] The call reference number is my name and today's date, and I spell my name [PII]
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I first initial your last name is [PII]. Uh-huh. Got it.
[AGENT][NEUTRAL] Mhm. and first initial.
[AGENT][NEUTRAL] That's right. I would have already given it to you.
[CUSTOMER][NEUTRAL] Yes. And then the day to day, correct?
[AGENT][NEUTRAL] Mhm
[AGENT][POSITIVE] That's correct.
[CUSTOMER][POSITIVE] OK, [PII]. So I hope that uh I get all the representatives like you and the previous representative list. You know, I'm feeling very happy today. Yeah.
[AGENT][NEUTRAL] Oh.
[AGENT][POSITIVE] Me too, [PII]. I hope I get them like you.
[CUSTOMER][POSITIVE] Thank you so much. Thank you.
[AGENT][POSITIVE] It's been a pleasure. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Um, oh no, I'm done with my questions and thank you so much for your help today. Bye, take care.
[AGENT][POSITIVE] Thank you, [PII]. Thank you, [PII]. Thank you for calling APL and you take care and have a lovely day.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Same to you. Bye.
[AGENT][NEUTRAL] Bye.