AccountId: 011433970860
ContactId: d4604f29-2f45-41ff-9444-632142dc066c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1410000 ms
Total Talk Time (AGENT): 573943 ms
Total Talk Time (CUSTOMER): 326165 ms
Interruptions: 2
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/04/d4604f29-2f45-41ff-9444-632142dc066c_20250404T13:50_UTC.wav
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[AGENT][NEUTRAL] Contacting APL, my name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], um, I'm calling regarding my patient's benefits. I got a fax already, but, um, I do have codes that I need to get frequency for.
[AGENT][POSITIVE] Yes, of course, I can help with that and, and with whom am I speaking?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII], thank you. And what is that policy number we're looking at today?
[CUSTOMER][NEUTRAL] Um, it is going to be, uh, give me the correct 1, 05 I'm sorry, 615428.
[AGENT][NEUTRAL] 428. Great, thank you. And the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Um, it is [PII] and last name is going to be [PII].
[AGENT][NEUTRAL] And her date of birth?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] OK, thank you. If I could just get a call back number please in the event that we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] OK, yes, and you said that there, uh, that there's certain codes that you need help with?
[CUSTOMER][NEUTRAL] Yes, I only, I'm only showing um.
[CUSTOMER][NEUTRAL] Preventative
[CUSTOMER][NEUTRAL] Codes on the fax back.
[CUSTOMER][NEUTRAL] And uh frequencies for those and I need um yes I need major and basic also and in the Imperial because frequencies.
[AGENT][NEUTRAL] OK, um,
[AGENT][NEUTRAL] Let's
[AGENT][NEUTRAL] Major and, OK. So is there, are there any uh particular codes that we need to be looking at, Ellie, or?
[CUSTOMER][POSITIVE] Yes, I can provide those for you.
[AGENT][NEUTRAL] Certainly, what's the first one?
[CUSTOMER][NEUTRAL] Is there a cer
[CUSTOMER][NEUTRAL] Um, 2330.
[AGENT][NEUTRAL] And the next one?
[CUSTOMER][NEUTRAL] Um, 2740.
[CUSTOMER][NEUTRAL] Oh never mind, I have that one sorry.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Um, next one is going to be 2.
[CUSTOMER][NEUTRAL] I'm sorry, 0220?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Then, um, do you want me to keep going or do you wanna do them one at a time?
[AGENT][NEUTRAL] Oh, yeah, just give me one more and then I can look these up and then we can go from there.
[CUSTOMER][POSITIVE] OK perfect um 2920.
[AGENT][NEUTRAL] OK, let me just see what we've got here and.
[AGENT][NEUTRAL] Uh, some of them have frequencies and some of them don't. Let me just.
[AGENT][NEUTRAL] OK. Excuse me, just a moment, please. I'll be right back. Excuse me, just one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, so for 2330.
[AGENT][NEUTRAL] It is uh replaced.
[AGENT][NEUTRAL] Replacement of existing only in place for 24 months.
[AGENT][NEUTRAL] The maximum of 1 each tooth for 24 months.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For 2740, let's see what we have here.
[AGENT][NEUTRAL] That is a maximum of 1 per seven-year period.
[AGENT][NEUTRAL] And it's limited to patients 16.
[AGENT][NEUTRAL] And over
[AGENT][NEUTRAL] Or um
[AGENT][NEUTRAL] 220 let's see what we have here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I don't have a limitation on that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For 2920.
[AGENT][NEUTRAL] OK, uh this uh for 2920, that will be um a maximum of 1 for seven-year period.
[AGENT][NEUTRAL] And that will be limited to patients 16 and over.
[AGENT][NEUTRAL] And then the next code?
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Um, so you, so crowns are once every 7 years.
[AGENT][NEUTRAL] Well, let's see, that's what it's saying. Let me go back.
[CUSTOMER][NEUTRAL] Yeah, because on the fax it said once every 5 years, but I don't know.
[AGENT][NEUTRAL] OK, so I'm looking
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 920. OK. OK, well then if that's OK, so on that case, yeah, OK, I see that. So on that one, that would be, yeah, it's once every 5, yeah, sometimes they'll, it's kind of.
[CUSTOMER][POSITIVE] OK perfect.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And then um next code will be 2950.
[CUSTOMER][NEUTRAL] Um, then we have 4346.
[AGENT][NEUTRAL] Now this uh that will be
[AGENT][NEUTRAL] OK. Now 29, 2950, that will be the same. It's once every 7 with um years with uh the patients being [PII] old and older.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then the next one.
[CUSTOMER][NEUTRAL] Um, I have 4341, but I have a question about that one. How many quads can be done?
[AGENT][NEUTRAL] Well, the quad, all 4 quads can be done at the same time as long as the patient has the um
[AGENT][NEUTRAL] Available benefits in their in their policy effect.
[CUSTOMER][NEUTRAL] OK perfect next code is 4346.
[AGENT][NEUTRAL] 4346.
[AGENT][NEUTRAL] Not sure that I've got anything on 4346. Let me just check here.
[AGENT][NEUTRAL] I can sure that 4346 is covered.
[AGENT][NEUTRAL] I'm not showing that on any of the, of the uh.
[AGENT][NEUTRAL] Benefits, so.
[AGENT][NEGATIVE] I'm not, I would go ahead and send it in, uh, if that's what you're doing 4346, but I'm not showing, I'm not sure that that's even covered.
[CUSTOMER][NEUTRAL] OK, you may pred it?
[AGENT][NEUTRAL] Yes, please, if you would.
[CUSTOMER][NEUTRAL] Predetermined perfect and then um what about 4355?
[AGENT][NEUTRAL] 55
[AGENT][NEUTRAL] The full mouth, I see. I think that's the same as.
[AGENT][NEUTRAL] So the debridement um that
[AGENT][NEUTRAL] is going to be um a maximum of one each quadrant.
[AGENT][NEUTRAL] For 24 months. And again, all 4 quads can be done if necessary, as long as they have the available benefits.
[AGENT][NEUTRAL] And the um
[AGENT][NEUTRAL] Policy is active and usually it is, I mean, it's we just have to make that.
[AGENT][NEUTRAL] I tell you that.
[CUSTOMER][NEUTRAL] You said 24 months correct?
[AGENT][POSITIVE] That's correct, yes.
[CUSTOMER][NEUTRAL] OK, yeah, because this fax is showing me different stuff, so I don't even know if this fax is correct, but I'm gonna go off of what you're saying because.
[CUSTOMER][POSITIVE] I trust you more so uh.
[CUSTOMER][NEUTRAL] You said 4355 correct these ones per quad per 24 months.
[AGENT][NEUTRAL] OK, yeah.
[AGENT][NEUTRAL] Yeah, that's, that's what it's showing.
[AGENT][NEUTRAL] Uh, just check here. Just a second. Excuse me just one moment please. I'll be right back. It's so that's some of the procedures are on there and some of them aren't and I wouldn't want because I'm wondering if uh.
[AGENT][NEUTRAL] Because it should be for this policy, it should be for this policy it should be every 12 months, but it's showing.
[CUSTOMER][NEUTRAL] That's what I'm seeing.
[AGENT][NEUTRAL] OK. Excuse me just a moment, please. Hold on forgive me just one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so for full milk debridement on this policy, it's gonna be every 12 months. Now every other policy, it's once every 24. So there are some things that are, that are, um, if, if we have any discrepancy between um.
[CUSTOMER][POSITIVE] OK perfect.
[AGENT][NEUTRAL] We'll always go by what's on this fax, OK? So that some of them will show uh just going by that code will show that, but on this particular one, it's a little bit special, and that's why it's kind of confusing. So it would be that 12 months for the debridement.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, is that, is that the same with like 2950 and 2954 since it's falling under this major?
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] That once every 5 years instead of once every 7.
[AGENT][NEUTRAL] Yes, it would be. Yes, that's it's, yeah, that's that's exactly right so that's um that would be just a little bit different from our other policies. So this one, yes, if you see anything on, on this, the frequencies or on this fax will be the ones that we go by, um.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][POSITIVE] Thank you again, I still have some more codes. I'm sorry.
[AGENT][POSITIVE] No, absolutely. What's the next one?
[CUSTOMER][NEUTRAL] Um, it's gonna be 4910.
[AGENT][NEUTRAL] The perio maintenance, OK.
[AGENT][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] I think it's once every 3 months. I just want to check here.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Normally it would be once every 6 months on this one that um
[AGENT][NEUTRAL] Periodontal, um, means it's gonna be once every 3 months.
[AGENT][NEUTRAL] It's just a little bit different here as opposed to the other.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And that one does not share with Profy or will it?
[AGENT][NEUTRAL] No, because the profies once it's still going to be once every 6 months.
[AGENT][NEGATIVE] But the, the, um, the cleanings once every 6, but the, but the um periodontal ones are once every 3 months. Again, kind of confusing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah and then um.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] And then uh what is the time after SRP?
[AGENT][NEUTRAL] What, what is the, you mean on um 4341?
[AGENT][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] On 4910.
[AGENT][NEUTRAL] Oh, on 4910. OK, let me just check here.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, 4910. So the periodontal maintenance, um, we're gonna go, it's going on this particular policy, it's once every 3 months.
[AGENT][NEGATIVE] Now, it does not share the frequency with with uh cleanings, which are once every 6.
[CUSTOMER][NEUTRAL] OK, and then the time limit after for 4910?
[AGENT][NEUTRAL] I am not showing a time limit. There there is nothing on here that indicates a time limit.
[CUSTOMER][NEUTRAL] So should I just put one day you think, or?
[AGENT][NEUTRAL] I would because it's just, there's, it's not, there's not anything that shows any sort of time limit for, you know, between those two procedures, so.
[CUSTOMER][NEUTRAL] OK perfect and then um I have a question about 0140.
[AGENT][NEUTRAL] OK, 0140, OK.
[CUSTOMER][NEUTRAL] Yes, would that be one every 6 months also with the other exams?
[CUSTOMER][NEUTRAL] I know sometimes the problem focus normally falls under different frequency.
[AGENT][NEUTRAL] Should
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, so the, so the, um, all the exams, uh, we have all, they should all fall under that, that same uh thing.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Um, yeah, it's supposed to be 120, 140, 150, 160, 180. Uh, they should all be exactly the same. Let me just see here. Uh.
[CUSTOMER][POSITIVE] Perfect.
[AGENT][NEUTRAL] Yes, so the exams are are all gonna be uh the same no matter what the um the code.
[CUSTOMER][NEUTRAL] OK, and then with that is um a treatment OK on the same day with 0140?
[AGENT][NEUTRAL] Yes, again, it, uh, it's, it's with the same limitations, you know, as long as the patient is active, they have available benefits. Yeah, that's always gonna be the, the thing that they look at.
[CUSTOMER][NEUTRAL] Perfect and then um for the next ones I just need to see if they're covered 5863.
[AGENT][NEUTRAL] 5863.
[AGENT][NEUTRAL] Check.
[AGENT][NEUTRAL] I don't think so, but let's see here.
[AGENT][NEUTRAL] I see.
[AGENT][NEUTRAL] No, I don't see that that's covered.
[CUSTOMER][NEUTRAL] OK, and is it, and then, um, are implants covered on this plan?
[AGENT][NEGATIVE] Uh, no, they are not.
[CUSTOMER][MIXED] Perfect. And then um so how about 5, 6058 sometimes that one's covered, but the rest aren't.
[AGENT][NEUTRAL] 5058, OK.
[AGENT][NEUTRAL] I don't think so, but let me just see.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Sure.
[AGENT][NEGATIVE] I don't see that they're covered.
[CUSTOMER][NEUTRAL] OK, that's, that's fine.
[CUSTOMER][NEUTRAL] Um, next one is my 771 11. This one I just need to see if it's covered also.
[AGENT][NEUTRAL] OK, 7111 is covered, um.
[AGENT][NEUTRAL] Let's see, there's any fragrancies for that.
[AGENT][NEUTRAL] I don't see any, but let me just.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] But it is covered at least. Um.
[CUSTOMER][NEUTRAL] OK and then what about.
[AGENT][NEUTRAL] OK. Yeah, 7111, yeah, that's, there's uh there is uh, let me just see. I'm sorry, I didn't mean to interrupt, um.
[AGENT][NEUTRAL] The the frequent, uh, the frequency on that one is um a maximum of one time per tube.
[CUSTOMER][NEUTRAL] You're fine.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So 70.
[CUSTOMER][NEUTRAL] 110 so they're all covered 72.
[CUSTOMER][NEUTRAL] 10
[CUSTOMER][NEUTRAL] But OK, and then does oral surgery get sent to medical first?
[AGENT][NEUTRAL] Well, no, I mean, because we don't have a coordination to benefits, so.
[AGENT][NEUTRAL] Um, you can, it's, yeah, just whatever it is you wanna do. If you wanna send it to medical first, that's great with us, but we don't coordinate the benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now that being said, if we don't that they have another, um, another policy, then we'll have to ask for an EOB or something like that. But otherwise, we never know. We just know what we have and, and we just go with that.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Perfect and then is Ortho covered?
[AGENT][NEGATIVE] Orthodontics isn't really covered under these policies, um.
[AGENT][MIXED] Be nice, but no.
[CUSTOMER][NEUTRAL] And then um palliative exam by [PII].
[AGENT][NEUTRAL] 9110. Let's see.
[AGENT][NEUTRAL] Uh, that is covered and
[AGENT][NEUTRAL] I don't know that there's a frequency, but let me just see.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] There isn't a frequency with that, um.
[CUSTOMER][NEUTRAL] OK, how about 9941?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Not sure that's covered the 9941.
[AGENT][NEUTRAL] Uh, that's not the accuser guard.
[AGENT][NEUTRAL] OK. I've got 9940, um.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] it's
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Those are, those are covered, but they're subject to review.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, I'm gonna put 3D.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, that's
[CUSTOMER][NEUTRAL] OK, and then what about clusive guards?
[AGENT][NEUTRAL] Those are subject to review.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] And then um is there any history on file that might affect for preventative and diagnostic?
[AGENT][NEUTRAL] This is for Alfred, right?
[CUSTOMER][NEUTRAL] Um, no, uh.
[AGENT][NEUTRAL] Oh, I'm Dei. I meant Dei. I'm sorry.
[CUSTOMER][POSITIVE] Yeah, you're good.
[AGENT][NEUTRAL] Yeah, OK, so.
[AGENT][NEUTRAL] So on [PII], the last thing that we have.
[AGENT][NEUTRAL] Now she had her inner oral X-rays on January the.
[AGENT][NEUTRAL] [PII] of this year.
[AGENT][NEUTRAL] Um, she also had a prophy. She had an oral examination.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Can I get those codes please? I'm sorry.
[AGENT][NEUTRAL] Oh yes, of course. Let me, yeah, let me go back to that um.
[AGENT][POSITIVE] Oh goodness.
[AGENT][NEUTRAL] Taking you through everything. I don't wanna do that. OK, so, um, [PII], uh, that is a procedure code uh 00230.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 00220.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 002.
[AGENT][NEUTRAL] The cleaning
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, yeah, so it's 230 and 220.
[AGENT][NEUTRAL] And then the cleaning
[AGENT][NEUTRAL] Is 01110.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] V
[AGENT][NEUTRAL] And this is all on the same day, uh, [PII], um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The next one is uh [PII], the periodic oral examination.
[AGENT][NEUTRAL] Now, that's everything for [PII]. Um.
[CUSTOMER][POSITIVE] OK perfect and that's all.
[AGENT][NEUTRAL] And that's the only thing, yeah, for the frequencies. Yeah, there's nothing else. Let's see.
[AGENT][NEUTRAL] Yeah, she hasn't had anything like bite wings or anything for a while, so.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And then what about for [PII]? Does he have anything that um affects?
[AGENT][NEUTRAL] So for him, uh, the last thing we have is from [PII], so no, he's, he should be available. Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and then um.
[CUSTOMER][NEUTRAL] Since we are out of network, y'all accept out of network fees on this plan, correct?
[AGENT][NEUTRAL] It's gonna be exactly the same. We don't have a network, um, so that uh that that fact sheet that you got will tell you exactly what we'll pay.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, and then what is the claim timely file limit it?
[AGENT][NEGATIVE] Uh, there's no, there's no timely filing on those.
[CUSTOMER][NEUTRAL] OK, payer ID?
[AGENT][NEUTRAL] It's 60801.
[CUSTOMER][NEUTRAL] And then do we pay on proper CD for grounds?
[AGENT][NEUTRAL] Uh, either of those two dates.
[CUSTOMER][NEUTRAL] And then um.
[CUSTOMER][NEUTRAL] Can I just get your name and a reference number please?
[AGENT][NEUTRAL] Yes, my name is [PII]. The first letter of my last name is [PII], and we're gonna use that today's date as a reference. Now, is there anything else at all that I may help with?
[CUSTOMER][POSITIVE] That is all thank you so much.
[AGENT][POSITIVE] OK, thanks for contacting AP have a good day.