AccountId: 011433970860
ContactId: d8a591ad-f5eb-45d6-a450-78fd16416c18
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 735580 ms
Total Talk Time (AGENT): 153157 ms
Total Talk Time (CUSTOMER): 211000 ms
Interruptions: 0
Overall Sentiment: AGENT=1.7, CUSTOMER=-1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/30/d8a591ad-f5eb-45d6-a450-78fd16416c18_20250130T19:58_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], my name is [PII]. I'm calling from a provider's office regard a dental claim please.
[AGENT][NEUTRAL] Hi.
[AGENT][NEUTRAL] OK, and if you would please spell your first name for documentation.
[CUSTOMER][POSITIVE] Absolutely it's [PII]
[AGENT][POSITIVE] Thank you so much. And may I also have your callback number if we are disconnected please [PII]?
[CUSTOMER][NEUTRAL] Sure, our office number is [PII].
[AGENT][NEUTRAL] Yes
[AGENT][POSITIVE] Thank you so much. And what is the policy number please for the patient?
[CUSTOMER][NEUTRAL] It is 02555870.
[AGENT][NEUTRAL] Thank you. And verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Our patient is [PII] and his date of birth is [PII].
[AGENT][POSITIVE] Thank you very much for the information, [PII] and again you're calling for a claim status. I can assist you with that give me one moment please.
[CUSTOMER][POSITIVE] Absolutely.
[AGENT][POSITIVE] Thank you so much. And may I have that date of service and the total charges, please?
[CUSTOMER][NEUTRAL] Um, it was [PII], [PII], and it was for 295.
[AGENT][NEUTRAL] Mm.
[AGENT][POSITIVE] Thank you so much. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And were there a total of 4 procedures that were performed with the member?
[CUSTOMER][NEUTRAL] I'm, I'm sorry, did you need the procedure codes that were performed?
[AGENT][POSITIVE] Yes, thank you.
[CUSTOMER][NEUTRAL] Um, sure, it was the 0120 periodic oral evaluation of an established patient, the 1120, which is a child prophylaxis.
[CUSTOMER][NEUTRAL] Um, the 1206 which is application of fluoride varnish and 0272 which are two bite wing X-rays.
[AGENT][POSITIVE] OK, thank you so much for that. And it shows that the claim was received and processed with a payment of $231. Again, that was $231 that was paid. I do have that claim and check number or both the claim and check numbers for you.
[CUSTOMER][NEUTRAL] Mhm I have we did receive it Miss [PII]. I, um, Doctor [PII] and I were reviewing it and we just had some questions because I know that this was based off of our being in network with Carrington Care PPO, um, and that's kind of what it said on the note to provider this claim was repriced according to your maximum care contract with Carrington Care PPO.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So we were under the impression um we submitted our UCR um which I see on the charge column.
[CUSTOMER][NEUTRAL] With Carrington, um, it's supposed to be, um, 20 minus 20% of our UCR, but um.
[CUSTOMER][NEUTRAL] I was we were looking at the um periodic examination under that scheduled column it's $74.
[CUSTOMER][NEUTRAL] So it's a little bit higher.
[CUSTOMER][NEUTRAL] It's, it's close to our UCR which we thought it was supposed to be.
[CUSTOMER][NEUTRAL] Our UCR less 20% so I'm not sure if this claim was not processed correctly.
[AGENT][NEUTRAL] OK. And yeah, again, that was for procedure code 0, I'm sorry, D0120. Is that correct?
[CUSTOMER][NEUTRAL] Mhm and then also for um 11:20 like under all of the well I guess those are the two procedure codes where it says um scheduled under the column but those amounts are not 20% of our UCR.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so for the exam and the 11:20, those are covered at 100%.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you see depending what our process.
[CUSTOMER][NEUTRAL] Of the allowable, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] May I place you on a brief hold please one moment angry, thank you.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][POSITIVE] No problem.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yeah
[AGENT][POSITIVE] Thank you so much for your patience. OK, now in procedure code, I'm sorry, thank you. 0120, the submitted charges, it shows.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] $76 just to make sure that and then $1120.
[AGENT][NEUTRAL] The flexes was $96.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said that.
[AGENT][NEUTRAL] It's different from your fees and I'm sorry, and your fee schedule fees is 93. I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Well, well, the
[CUSTOMER][NEUTRAL] Yeah, so technically what our agreement with Carrington care is is we were supposed to receive 20% less than our regular UCR.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] On those codes.
[CUSTOMER][NEGATIVE] So instead of the 96% we should have received 6880 which is 80% of our UCR.
[AGENT][NEUTRAL] And what is
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] We just wanted to, we didn't wanna cash this check if it was incorrect.
[AGENT][NEUTRAL] I understand, I understand, um, I was trying to see if I can actually let you speak with the adjuster process to claim, but um.
[AGENT][NEUTRAL] It was
[AGENT][NEUTRAL] Processed correctly see schedule 93.
[AGENT][NEUTRAL] 23.
[AGENT][NEUTRAL] OK, can I place you on a brief hold and see if I can reach out to the examiner real quick, OK, but before that, so with and with the example for [PII], you said that 80 20% of that was 68.
[CUSTOMER][NEUTRAL] Sure, sure.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] 11:20 um what for that code um our UCR is $96 so we were expecting to receive $76.80 which is $96 minus 20%.
[AGENT][NEUTRAL] OK, so you were expecting a payment of 7680 for that particular code. Is that correct to say?
[CUSTOMER][POSITIVE] Correct, correct, and, and all the other the other ones as well, but that's yes.
[AGENT][NEUTRAL] OK. All right.
[AGENT][POSITIVE] OK, OK, one moment please thank you.
[CUSTOMER][NEUTRAL] Sure, sure.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.