AccountId: 011433970860
ContactId: cfed28e4-77cb-433b-84f6-0926aaa9f8ce
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 624940 ms
Total Talk Time (AGENT): 287282 ms
Total Talk Time (CUSTOMER): 252509 ms
Interruptions: 1
Overall Sentiment: AGENT=1.5, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/02/cfed28e4-77cb-433b-84f6-0926aaa9f8ce_20250102T22:09_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Cause I had a question about my dental insurance.
[AGENT][NEUTRAL] Uh-huh, yeah, how can I help you?
[CUSTOMER][NEUTRAL] Um, so,
[CUSTOMER][NEUTRAL] The way I guess they said the way my insurance works is after 12 months they pay up to 40%.
[CUSTOMER][NEUTRAL] Of dental work up to $1500 per year.
[AGENT][NEUTRAL] OK, um, can I, do you have your policy number handy and I can pull up your individual plan?
[CUSTOMER][NEUTRAL] Uh, I don't have my policy number. Can I give you like my social or something?
[AGENT][POSITIVE] Yeah, I can search for your social um and I'm ready for that when you are.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And your
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] First, OK, perfect, thank you.
[AGENT][NEUTRAL] And would you be able to verify for me, sir, your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Wonderful. And I just need to verify a couple other pieces of information if you wouldn't mind verifying your mailing address.
[CUSTOMER][NEUTRAL] Yeah, uh,
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Looks like the address I have might be different. Did you move recently and have a previous address on file?
[CUSTOMER][NEUTRAL] Uh, you got the [PII].
[AGENT][NEUTRAL] Uh, it looks like
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] The one I have is in [PII] City.
[CUSTOMER][NEUTRAL] Uh, the [PII].
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, that's, yeah, that's I moved, yeah, I'm sorry, I thought I'd changed it.
[AGENT][POSITIVE] OK, no worries I can help get that updated for you as well today. Would you be able to verify just your email address and your phone number real quick for me then?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[CUSTOMER][NEUTRAL] And um [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Perfect and that number is good to call you back on if we got disconnected, sir?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] All right. And let me
[AGENT][NEUTRAL] Get into your policy where I can change the address for you.
[AGENT][NEUTRAL] And what's gonna be that address on file for you instead, my friend?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII] um
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what's the zip code?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK perfect thank you so much.
[AGENT][NEUTRAL] All right, and that should be updated now for you. And then, yes, it looks like with your plan, um you did have to do a 12 month waiting period for your major medical expenses to be covered and oral surgery expenses, and they are covered at 40% of the usual and customary rate, uh, which is based off your zip code.
[AGENT][NEUTRAL] And it does look like your benefit is up to $1500 per calendar year with a $50 deductible. Um, I do wanna let you know though any benefit information I give you over the phone is just a verification of coverage. It's never a guarantee of payment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, did you have any other questions on your policy today, Mr. [PII]?
[CUSTOMER][NEUTRAL] Yeah, so if they're doing it, if they're.
[CUSTOMER][NEUTRAL] So say the total bill is like 29.
[CUSTOMER][NEUTRAL] 85.
[CUSTOMER][NEUTRAL] But they're breaking it down into
[CUSTOMER][NEUTRAL] 3
[CUSTOMER][NEUTRAL] Uh, parts, I guess they make 3 different sessions if that makes sense.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Then how would that 40% work? Would that still go over the total amount or would that be billed as 40% off of each?
[CUSTOMER][NEUTRAL] Appointment since they're they're doing it in 3 different.
[AGENT][NEUTRAL] Yeah, so what that's gonna do is.
[AGENT][NEUTRAL] The your facility every time you go I believe they'll probably submit 3 separate claims, one for each session, um, so it really depends on how it comes through if they send it all together as one, then it will come through all together as one, but typically they'll send a claim after the work is done for the work that was done at that visit.
[AGENT][NEUTRAL] And then they're going to look at what procedure codes you had, if it's a covered code, um, it will be at what percent, so your preventative codes are gonna be covered at 100%, your basic codes are covered at 80%, and your um major and oral surgery codes are covered at 40%.
[AGENT][NEUTRAL] And so they'll look what the the rate is they they call it usual and customary it's based off your zip code, what that rate is and they'll pay a percentage of that to the provider and then typically the provider would bill you for anything that wasn't covered.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] So, so, basically this is being done in sections in, in 3 different sessions. I'm not being able to use that full.
[CUSTOMER][NEUTRAL] 1500 because it's gonna be 40% off that amount for that particular appointment at that time.
[CUSTOMER][NEUTRAL] You said off the overall amount.
[AGENT][NEUTRAL] Yeah, so that $1500 isn't like a bulk amount like that is what your available benefits are for the calendar year, but it's not like a lump sum sort of so if we cover like your preventative was $100 it would be $100 of that $1500 and then if you had a basic procedure for $200 it's gonna cover $160 and it's gonna add those up into the total benefit of the $1500.
[CUSTOMER][NEUTRAL] Right, yeah.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, so you should be able to every claim that comes on will keep going until you hit that benefit amount, um, on what they're able to cover for you.
[AGENT][NEUTRAL] There is a $50 deductible on here. I do wanna let you know, um, it doesn't count towards your preventative but uh you do have a $50 deductible on your plan as well.
[CUSTOMER][NEUTRAL] I mean
[CUSTOMER][NEUTRAL] So, so
[CUSTOMER][NEUTRAL] I guess, I guess with my, I guess they would break because I guess they're saying that out of that 2985 or whatever, the insurance is going to pay 1,0083.
[AGENT][NEUTRAL] OK, I um.
[CUSTOMER][NEUTRAL] They're gonna pay like
[AGENT][NEUTRAL] I won't be able to tell you like how much we can pay until like they do have our breakdowns um so they might have already looked at the codes and see what the the usual customary rates are and be able to give you an estimated breakdown but we can't tell like how much is gonna be paid off something until we have the claim in hand.
[CUSTOMER][NEUTRAL] OK, yeah, that there's no claim. I had to reschedule because it was, yeah, they didn't, they said it was too confusing for them for the insurance, so.
[CUSTOMER][NEGATIVE] Basically I had to miss the appointment because they couldn't figure out what the insurance was doing on their end, so.
[CUSTOMER][NEGATIVE] That is my, that is my frustration for the day. I sat there for an hour and didn't get no work done because they said that the insurance was too confusing as, as far as how they were doing it and what they were gonna pay, so.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEGATIVE] I have to reschedule my appointment.
[AGENT][POSITIVE] That is crazy. I'm so sorry. They definitely.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] That's not that that's, that's, that's very crazy with how hard it is for me to get off work being a truck driver. That is very crazy, and it's, it's very frustrating because I'm like, why wasn't this done prior to me coming to the appointment? Like, why would you do this as soon as I walk in and leave me sitting there for 1 hour and then an hour later say, oh, we need 2 hours for your procedure and an hour has passed, so now we got to reschedule. As hard as it is for me to even get off or be off to do a dentist appointment, it is like frustrating to me. I'm like.
[CUSTOMER][NEUTRAL] Yeah, so
[CUSTOMER][NEUTRAL] And, uh, so that's why I was trying to call to get a, uh, some kind of understanding on it because like right now the frustration level is high, but.
[CUSTOMER][POSITIVE] Thank you for, uh, trying to explain it to me and or explaining it to me. So that kind of gave me a little better understanding of it, so.
[AGENT][NEUTRAL] Absolutely I'm really sorry that you weren't able to get the work done but if your provider, I mean I know you've already been in, but if they need anything from us, like we have a full breakdown of benefits that goes over every code um and tells you how much of it is covered, um, the only thing that doesn't list.
[CUSTOMER][NEUTRAL] They showed, they showed me the, the paperwork. They showed, so I'm like, if it was confusing because y'all not just called them before like.
[CUSTOMER][NEGATIVE] I don't, I'm, I'm still not understanding that. Like, what was the confusion of that? Like, they have the paperwork and they was like, here, we can sell you the paperwork. This is what it's paying, but it was the, the problem with that, that I was confused from is what they're saying that they will pay now.
[CUSTOMER][NEUTRAL] Is basically the same amount that if I would have gotten it done like last year before the [PII] hit, it's the same amount. So they told me if I waited to the [PII], then more would be paid out.
[CUSTOMER][NEUTRAL] So 2 weeks ago I rescheduled appointments until now.
[CUSTOMER][NEUTRAL] And they're like, oh, well, this is what they're paying the same amount as.
[CUSTOMER][NEGATIVE] They, you know, I'm like, so what was the point of me waiting till the [PII] for y'all to tell me to wait till the.
[AGENT][POSITIVE] To the [PII], exactly, and it seems like they have plenty of time to sit there and create an estimate based off the codes.
[CUSTOMER][NEUTRAL] That's what, that's what I would think. That's what I would think. I'm like, if that was the case, I could have just got it done, you know, two weeks ago, instead of waiting till the [PII]. So I don't know, but, OK.
[AGENT][NEUTRAL] Uh
[AGENT][POSITIVE] Well, Mr. [PII], I'm really sorry about that. If there's anything else we can do on our end, please let us know we'd be happy to help you out and I am.
[AGENT][NEUTRAL] I'm sorry for the confusion that this is all caused you, but.
[CUSTOMER][POSITIVE] No, no problem, no problem at all, thank you for your time.
[AGENT][POSITIVE] Hey, it's my pleasure. Thank you so much. I hope you have a wonderful day and a happy new year.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Thanks. Bye bye.