AccountId: 011433970860
ContactId: e5ef7407-09a8-461b-84b9-0ba3e9f1c270
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 740260 ms
Total Talk Time (AGENT): 311641 ms
Total Talk Time (CUSTOMER): 135490 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/24/e5ef7407-09a8-461b-84b9-0ba3e9f1c270_20250324T21:38_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], good afternoon. My name is [PII].
[AGENT][POSITIVE] Hey, [PII]. How can I help today?
[CUSTOMER][NEUTRAL] Yeah, I was calling out to get a benefit breakdown and to see if we're in network with this uh patients plan.
[AGENT][POSITIVE] OK, I'm happy to check on benefits today. What's the patient's policy number?
[CUSTOMER][NEUTRAL] 02607909
[AGENT][NEUTRAL] All right, thank you. And do you have a good callback number just in case if we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's [PII], no extension.
[AGENT][NEUTRAL] Thank you, and then patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you so much. So the patient's plan is active. The effective date on here is [PII].
[AGENT][NEUTRAL] Patients plan looks like does participate in the Carrington PPO network. Uh, it is not required for usage though. Plan pays by uh UCR it looks like.
[CUSTOMER][NEUTRAL] And Doctor [PII] is um like in work or out of network or?
[AGENT][NEUTRAL] Uh, we don't have any way to check to see if the provider is in network or out of network. The plan does participate in the Carrington PPO network. Do you know if your providers in that network?
[CUSTOMER][NEUTRAL] Mm, I don't, but I can figure out if not, we can use the UCRC, right?
[AGENT][POSITIVE] Yeah, absolutely. And if you need, we can also send a fax back with the breakdown.
[CUSTOMER][NEUTRAL] Um, what is the payer ID number?
[AGENT][NEUTRAL] 60801.
[CUSTOMER][NEUTRAL] Is there a group name?
[AGENT][NEUTRAL] Uh, let me look at the plan here. One moment.
[AGENT][NEUTRAL] The group name is Lark LLC and there's a group number if you need that.
[CUSTOMER][NEUTRAL] What was the name of the group name? Was it?
[AGENT][NEUTRAL] Lark. So it's L as in Larry, A R K as in kite.
[AGENT][NEUTRAL] LLC.
[CUSTOMER][NEUTRAL] And then the group number please?
[AGENT][NEUTRAL] 70083.
[CUSTOMER][NEUTRAL] And does this time around a calendar year or is it a fiscal year plan, ma'am?
[AGENT][NEUTRAL] Calendar year.
[CUSTOMER][NEUTRAL] And they're missing tooth cloths or waiting period?
[AGENT][NEUTRAL] Uh, let me see if this one has.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] This policy does have a missing tooth clause, no waiting periods on the plan.
[CUSTOMER][NEUTRAL] Is there a yearly maximum?
[AGENT][NEUTRAL] Uh, yeah, looks like their calendar year max is 500 and the calendar year deductible is 50, up to 150 for the family.
[CUSTOMER][NEUTRAL] And those 500, it applies to preventative basic and major?
[AGENT][POSITIVE] Yes it does.
[CUSTOMER][NEGATIVE] And the deductible what applies only to basic and major.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And does she have all $500 left?
[AGENT][NEUTRAL] Uh, let me double check to see if anything has been used. One moment.
[AGENT][NEUTRAL] Uh, looks like patient has full amount remaining for the year.
[CUSTOMER][NEUTRAL] OK, what are the insurance co-insurance or preventative basic and major?
[AGENT][NEUTRAL] So it looks like this plan has preventative covered at 100%.
[AGENT][NEUTRAL] And then basic at 80, there is no major coverage on the patient's plan.
[CUSTOMER][NEUTRAL] All righty. Um, endoperio and oral surgery, are they all covered at 80 or are they considered major?
[AGENT][NEUTRAL] They're all considered majors, so not covered.
[CUSTOMER][NEUTRAL] And then for 23.92 billing, is there a frequency for that?
[AGENT][NEUTRAL] Let me see. 2392, 1 moment.
[AGENT][NEUTRAL] So 2392 is listed under basic restorative, so that's covered at 80%. Let me see what the limitation is one moment.
[AGENT][NEUTRAL] So it looks like it's a maximum of 1 each tooth for 24 months and replacement only existing if in place for 24 months.
[CUSTOMER][NEUTRAL] Do you downgrade?
[AGENT][NEUTRAL] No downgrade.
[CUSTOMER][NEUTRAL] And there's no crown benefit because that's major. What about 4341?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 4371.
[CUSTOMER][NEUTRAL] No, 43, 41.
[AGENT][NEUTRAL] I'm sorry, 4341.
[AGENT][NEGATIVE] I do not see 4341 listed, so therefore it's not covered.
[CUSTOMER][NEUTRAL] 0364.
[AGENT][NEUTRAL] I do not see 0364 listed.
[CUSTOMER][NEUTRAL] Um, 4355.
[AGENT][NEUTRAL] Uh, no, 4355 either.
[CUSTOMER][NEUTRAL] OK, what about an SMX 0210?
[AGENT][NEUTRAL] Uh, so that is covered at 80% and it looks like it's limited to one X-ray procedure for 5 years. Um, it does share frequency with 03300277.
[CUSTOMER][NEUTRAL] OK, what about PA 0220?
[AGENT][NEGATIVE] Looks like that's covered under basic at 80%. I do not show any limitation.
[CUSTOMER][NEUTRAL] 0274
[AGENT][NEUTRAL] 02
[AGENT][NEUTRAL] 0274 is covered under preventative, so that's at 100%.
[AGENT][NEUTRAL] And it looks like it's limited to one bite wing X-ray per 12 months. It does share frequency with 0270 and 272.
[CUSTOMER][NEUTRAL] And exam 0150.
[AGENT][NEUTRAL] That's covered at 100% under preventative and it does carry a limitation.
[AGENT][NEUTRAL] evaluations and a 12 month period.
[CUSTOMER][NEUTRAL] How many?
[AGENT][NEUTRAL] 2
[AGENT][NEUTRAL] In a 12 month period.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] OK, and then for 0120?
[AGENT][POSITIVE] That's covered at 100%.
[AGENT][NEUTRAL] And it looks like it's a maximum of one per lifetime per quadrant or arc.
[CUSTOMER][NEUTRAL] 0120, an exam?
[AGENT][NEUTRAL] Yeah, let's see.
[AGENT][NEUTRAL] Oh, sorry.
[AGENT][NEUTRAL] Wrong one limited to 2 per 12 month period. I apologize. It's covered at 100%, 0120.
[CUSTOMER][NEUTRAL] OK, thank you. What about 0140?
[AGENT][NEUTRAL] 0140 is under basic.
[AGENT][NEUTRAL] So that would be at 80%.
[AGENT][NEUTRAL] And it's limited to 2 in any 12 month period.
[CUSTOMER][NEUTRAL] Does it share frequency with the 0120?
[AGENT][NEUTRAL] Mhm, yes, it does.
[CUSTOMER][NEUTRAL] What about 1110?
[AGENT][NEUTRAL] 11 10s listed under preventative, so that would be at 100%.
[AGENT][NEUTRAL] It's a maximum of 1 procedure per 6 months.
[CUSTOMER][NEUTRAL] 12:08.
[AGENT][NEUTRAL] 1208.
[AGENT][NEUTRAL] I do not show 1208 listed.
[CUSTOMER][NEUTRAL] What about 4910?
[AGENT][NEUTRAL] I do not see 4910 either.
[CUSTOMER][NEUTRAL] Z 1351.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] He is listed under preventative at 100%. It does have some limitations. One moment.
[AGENT][NEUTRAL] It looks like it's a maximum of 1 procedure per 36 months. It is limited to dependent children under the age of [PII], and then it says applications to permanent molar teeth only.
[CUSTOMER][NEUTRAL] OK, um, can I have a reference number for this call, please?
[AGENT][NEUTRAL] Absolutely. Call reference is my name with my last initial than today's date. My name again is [PII], last initial is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Awesome. OK, thank you so much, [PII] have a good evening.
[AGENT][NEUTRAL] You too, [PII]. Bye-bye.