AccountId: 011433970860
ContactId: e421bc64-9f9b-4a5e-920b-a0f4f0053c92
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 701150 ms
Total Talk Time (AGENT): 192139 ms
Total Talk Time (CUSTOMER): 265458 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/28/e421bc64-9f9b-4a5e-920b-a0f4f0053c92_20250228T21:22_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hi, [PII], good afternoon. My name is [PII]. How are you today?
[AGENT][POSITIVE] I'm good how are you?
[CUSTOMER][POSITIVE] I'm doing fine. Thank you. Thank you for asking.
[AGENT][NEUTRAL] And how can I assist?
[CUSTOMER][NEUTRAL] And, uh, uh, [PII], I'm calling regarding a patient eligibility and uh, the breakdown of the benefits, uh, question for the maximum history. Uh, can you help me with that, please?
[AGENT][POSITIVE] I'd be happy to assist with patient eligibility today [PII] if I can get a good call back number for you.
[CUSTOMER][NEUTRAL] Oh yes, callback number is [PII] again [PII].
[AGENT][NEUTRAL] And what's the policy number?
[CUSTOMER][NEUTRAL] Policy number is
[CUSTOMER][NEUTRAL] 02465237
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] The patient is [PII], first name [PII], last name, date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that information. Please be advised the verification of coverage is not a guarantee of payment. I do show the policy is currently active. Effective date is [PII].
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] You were wanting the um maximum?
[CUSTOMER][POSITIVE] Oh yes, please.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, I'm showing that um she hasn't used any of her um benefits so far this year. She will need to meet the, um.
[AGENT][NEUTRAL] $50 deductible.
[AGENT][NEUTRAL] And she has the full $1500 available.
[CUSTOMER][NEUTRAL] 1500 is the maximum.
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Great. And uh we are in network with the patient plan.
[AGENT][NEUTRAL] Um, yes, we don't have a network so the patient can see any provider that they choose. We go by user on customary rates.
[CUSTOMER][NEUTRAL] Oh, the, the fees, uh, your fee.
[AGENT][NEUTRAL] Yeah, UCR.
[CUSTOMER][NEUTRAL] You see our search here and
[CUSTOMER][NEUTRAL] Uh, what is the group name and group number?
[AGENT][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] Group number is gonna be 17626.
[AGENT][NEUTRAL] And group name is Universal Trucking.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Great. And the
[CUSTOMER][NEGATIVE] Uh, the plan have missing too close or waiting period.
[AGENT][NEUTRAL] Um, yes, her waiting period will be up [PII], excuse me, [PII] of this year, and there is a missing two clause.
[CUSTOMER][NEUTRAL] Oh, waiting period, it's for uh any um specific for major or basic.
[AGENT][NEUTRAL] Just for major, just for major mhm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Sure. OK.
[CUSTOMER][POSITIVE] Great, great. And
[CUSTOMER][NEUTRAL] Uh, what is the best address to send the claim?
[AGENT][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that's in [PII]?
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][POSITIVE] Great.
[CUSTOMER][NEUTRAL] And only have uh individual deductible or they have family deductible?
[AGENT][NEUTRAL] Um, family deductible is 150.
[CUSTOMER][NEUTRAL] Mm OK.
[CUSTOMER][NEUTRAL] And um any of those is met?
[AGENT][NEGATIVE] Um, no, no one's used any benefits so far this year.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] And this that runs on their calendar or fiscal year?
[AGENT][NEUTRAL] Calendar.
[CUSTOMER][NEUTRAL] OK. And what is the payer ID?
[AGENT][NEUTRAL] 60801.
[CUSTOMER][POSITIVE] OK, good.
[CUSTOMER][NEUTRAL] And uh the plan have auto benefits.
[AGENT][NEUTRAL] No, no Ortho.
[CUSTOMER][NEUTRAL] No heart. And they have implant coverage?
[AGENT][NEGATIVE] Uh, no, no implant coverage.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And they have downgrades for feelings or crowns.
[AGENT][NEUTRAL] I'm sorry, repeat that for me.
[CUSTOMER][NEUTRAL] Um, if they have, uh, languages for feelings or crowns.
[AGENT][NEUTRAL] Well that would be considered now the fillings are basic but the crown, that would be considered major and subject to the waiting period. Um, did you need a fax back of the uh list of coding that is covered under the policy?
[CUSTOMER][POSITIVE] Oh yes, I appreciate that.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what's that fax number?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] Alright, you should receive that within the next 10 minutes. Was there anything else I could assist with today?
[CUSTOMER][NEUTRAL] Oh yes, uh, the, the plan have, sorry, uh, they have history that affect eligibility, uh, [PII], they have history.
[AGENT][NEUTRAL] Um, she had, uh, let's see.
[AGENT][NEUTRAL] X-rays. She had treatment on [PII].
[AGENT][NEUTRAL] And so she had X-rays.
[AGENT][NEUTRAL] She had a panel, bye wings, comprehensive oral exam.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] And it's the only history they have.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And
[CUSTOMER][NEUTRAL] Um, the, the crowns are paid on prep date or C date?
[AGENT][NEUTRAL] C
[CUSTOMER][NEUTRAL] And core buildup and crown can be made on the same day.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the extraction code they need to send it to medical first or straight to dental.
[AGENT][NEUTRAL] Um, for extracting, um.
[AGENT][NEUTRAL] What do you mean?
[CUSTOMER][NEUTRAL] Oh, if, uh, they need to send to medical first or only straight to, to dental?
[CUSTOMER][NEUTRAL] The the the claims, extraction claims.
[AGENT][NEUTRAL] So I don't think I quite understand your question.
[CUSTOMER][NEUTRAL] No, no, so if the extraction need to send or need a doctor review or only we need to send the, the.
[CUSTOMER][NEUTRAL] The claims for OS or extraction straight to to the dental insurance.
[AGENT][NEUTRAL] No, I mean you would be able to send it straight to us if it's uh if if you're billing with a dental code now if you're billing with a a medical code.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And they're having, having it pulled in the hospital, then that will go to their medical.
[CUSTOMER][NEUTRAL] OK, and the SRP it's for 2 quads per visit or all 4 quads on the same visit?
[AGENT][NEUTRAL] Um, all 4.
[CUSTOMER][NEUTRAL] Mhm. And the perium maintenance they share frequency with profiy or other codes.
[AGENT][NEUTRAL] Um, no.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh the FMX and panel they share pregnancy.
[AGENT][NEUTRAL] FMX and panel, I believe they do hold on.
[AGENT][NEUTRAL] Uh, yes, once, once every 5 years.
[CUSTOMER][NEUTRAL] OK. And the exams like 0 150, 0120, and 0140, they share frequency between them.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, uh, treatment and exam can be done on the same day.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK, great. Oh, and about the downgrades, um, they need to submit a predetermination or they have a, an alternative, uh, codes for for that?
[AGENT][NEUTRAL] We don't do downgrades.
[CUSTOMER][NEUTRAL] Oh, not that much, OK.
[CUSTOMER][NEUTRAL] OK, great. And, and what is the um
[CUSTOMER][NEUTRAL] Percentage for preventative basic and measure the insurance level.
[AGENT][NEUTRAL] Preventative is 100%, basic is 80, major is 40.
[CUSTOMER][NEUTRAL] OK. OK, OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Uh, uh,
[CUSTOMER][NEUTRAL] And [PII], can you help me with a few procedure codes uh frequency and percentage?
[AGENT][NEUTRAL] Um, coding we don't give verbally. You have to get it on the fax back.
[CUSTOMER][NEUTRAL] Oh, on the fax. OK. And if it, it's not on the fax, uh, I suppose it's not covered. Oh, OK, great, great. And can you help me also with the main subscriber, uh, maximum and history is, is, uh, under, under the same.
[AGENT][NEGATIVE] It's not covered.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] And their name and date of birth?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] The name is hold on, it's [PII].
[CUSTOMER][NEUTRAL] [PII], date of birth, [PII].
[AGENT][NEUTRAL] Thank you for that information. I'm not showing he has any history. He hasn't used any of his benefits.
[CUSTOMER][NEUTRAL] Any history. Oh, OK, OK, OK, great. And [PII], for very last, uh, and thank you so much for that. Uh, can you help me with the reference number of the call?
[AGENT][NEUTRAL] Reference is just my name and today's date and time. Was there anything else I could assist with today?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Uh, no, and, well, thank you so much for that, [PII], and I appreciate your time and your help and uh have a wonderful day.
[AGENT][POSITIVE] Thank you for calling APL. You too. Have a good day.
[CUSTOMER][POSITIVE] And a wonderful weekend too.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.