AccountId: 011433970860
ContactId: e9844a4a-6f3e-4b8d-8658-8ddcd35db7d9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 605609 ms
Total Talk Time (AGENT): 250100 ms
Total Talk Time (CUSTOMER): 211704 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/e9844a4a-6f3e-4b8d-8658-8ddcd35db7d9_20250213T14:53_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][POSITIVE] Hi good morning I was calling to get benefits for a patient.
[AGENT][NEUTRAL] OK, I can verify benefits for you and your name is?
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] OK, Ms. [PII], what is that policy number, please?
[CUSTOMER][NEUTRAL] OK, so it is going to be, uh, I'm sorry.
[AGENT][NEUTRAL] No, you're fine.
[CUSTOMER][NEUTRAL] 02461575
[AGENT][NEUTRAL] Thank you. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] OK, and Ms. [PII], verify the patient's name, date of birth.
[CUSTOMER][NEUTRAL] Uh [PII], [PII].
[AGENT][NEUTRAL] OK, I'm showing his effective date is [PII]. He is active on the policy, and I just need a general breakdown of benefits or I can send you a fax back. OK?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] Um, not a guarantee of payment, just verification of coverage. Uh, the patient has benefit max of up to $1500 per calendar year and a $50 deductible that is applied to everything but preventative services.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Preventative pays 100% of UCR. Basic, basic restorative FMX panoramic pays at 80%, and for major services which would include endoperio oral surgery, it pays at 40.
[CUSTOMER][NEUTRAL] And no pay or so major as well, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, uh, any waiting periods or missing tooth cloth?
[AGENT][NEUTRAL] Um, there is a 12-month waiting period for major services, but they have already passed that waiting period. Well,
[AGENT][NEUTRAL] They will pass the waiting period for major on [PII] of this year.
[CUSTOMER][NEUTRAL] OK, hold on, major.
[CUSTOMER][NEUTRAL] You said [PII] of this year.
[AGENT][NEUTRAL] Yes, ma'am. Then they'll have met their waiting period. Go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, you're fine. Um, is there a family deductible?
[AGENT][NEUTRAL] Uh, it's up to 150 per year.
[CUSTOMER][NEUTRAL] OK, and then the group name and group number?
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] Uh, group number 16068.
[AGENT][NEUTRAL] A group name is Universal Trucking, Hirschbach, and I spell it for you. H I R S C H B A C H.
[CUSTOMER][NEUTRAL] OK, Universal trucking.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] H I S C H.
[CUSTOMER][NEUTRAL] B A C H right is the last?
[AGENT][NEUTRAL] Uh, BACH, yes, ma'am.
[CUSTOMER][NEUTRAL] OK, and you said agreement on 16068?
[AGENT][NEUTRAL] Uh, yes, ma'am.
[CUSTOMER][NEUTRAL] OK and then um.
[CUSTOMER][NEUTRAL] So FOX is covered at 80%. What about the other X-rays?
[AGENT][NEUTRAL] Uh, panels at 80, bite wings are considered major, I mean, I'm sorry, preventive, so it pays 100%, PAs, uh, those are considered basic, so it pays at 80.
[CUSTOMER][NEUTRAL] And those go towards um.
[CUSTOMER][POSITIVE] Deductible correct.
[AGENT][POSITIVE] Correct. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, does Profi Imperial Maintenance share frequency?
[AGENT][NEGATIVE] Uh, no.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the 0140, does that show with the regular exams?
[AGENT][NEUTRAL] All exams share the same frequency of 2 for 12 month period.
[CUSTOMER][NEUTRAL] And treatment is allowed the same day?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, and is that cover at 100% as well?
[AGENT][NEUTRAL] The 140?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I think that falls within basic. Let me double check.
[AGENT][NEUTRAL] Uh yes, ma'am, that falls within basic. So, uh, deductible applies and it pays at 80.
[CUSTOMER][NEUTRAL] OK, and what's the um frequency and coverage for Florida sealants?
[AGENT][NEUTRAL] Uh, fluoride is, I'm sorry, fluoride is under the age of [PII], once every 12 months, sealants under the age of [PII], permanent molars only once every 3 years.
[CUSTOMER][NEUTRAL] OK, and on the 4341, how many quads do you guys allow the same day?
[AGENT][NEUTRAL] All 4 can be done on the same day.
[CUSTOMER][NEUTRAL] OK, and on the 4255, does that downgrade to a pro fee?
[AGENT][POSITIVE] Uh, no, there are no downgrades.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Or surgery goes to medical or to dental?
[AGENT][NEUTRAL] Uh, it can come to dental.
[CUSTOMER][NEUTRAL] Do composites downgrade to amalgam.
[AGENT][NEUTRAL] Uh, no, ma'am. There are no downgrades.
[CUSTOMER][NEUTRAL] 1 2nd.
[CUSTOMER][NEUTRAL] And what's the frequency for composites?
[AGENT][NEUTRAL] Uh, once every 24 months.
[CUSTOMER][NEUTRAL] Uh it's every 24.
[CUSTOMER][NEUTRAL] And then the 2930, does that one have an age limit?
[AGENT][NEUTRAL] 2930, uh, what is that code for? No, don't tell me. Oh.
[CUSTOMER][NEUTRAL] A
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Oh, stainless steel crowns, um.
[AGENT][NEUTRAL] You said there is there an age limit?
[CUSTOMER][NEUTRAL] Uh huh
[AGENT][NEUTRAL] Under the age of [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK, and crowns are paid on prep date or C date?
[AGENT][NEUTRAL] Uh, either or.
[CUSTOMER][NEUTRAL] Our purpose
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And do you guys accept assignment of benefits?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] And does he have a message in his class?
[AGENT][NEGATIVE] Uh, there is a missing tooth cloth. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, and are his coordination of benefit standard?
[AGENT][NEUTRAL] It is standard.
[CUSTOMER][NEUTRAL] OK, and what's uh this one on a calendar year?
[AGENT][NEUTRAL] It does.
[CUSTOMER][NEUTRAL] OK hold on.
[CUSTOMER][NEUTRAL] And then is there a filing deadline for claims?
[AGENT][NEUTRAL] No, ma'am, there is no deadline.
[CUSTOMER][NEUTRAL] And this is a PPO correct?
[AGENT][NEUTRAL] Um, I guess you say that. We don't have any network or list of providers.
[CUSTOMER][NEUTRAL] OK, got you. And can I get the claims address and payer ID?
[AGENT][NEUTRAL] Yes, ma'am. It's [PII].
[CUSTOMER][NEUTRAL] Wait, hold on. [PII], OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, and the payer ID.
[AGENT][NEUTRAL] Uh, [PII]. I apologize.
[CUSTOMER][NEUTRAL] Hold on let me [PII].
[AGENT][POSITIVE] Uh, correct.
[CUSTOMER][NEUTRAL] 801 OK and then can I get his date of er his last day of service on history please.
[AGENT][NEUTRAL] Uh, let's see if he has.
[AGENT][NEUTRAL] See.
[AGENT][NEUTRAL] Uh, looks like the, he had sealants and this was on [PII].
[AGENT][NEUTRAL] And it looks like FMX on [PII] as well, as well as exam.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 1 2nd.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I had to wait. She said she was gonna think about and tell me to.
[CUSTOMER][NEUTRAL] I'll ask.
[CUSTOMER][NEUTRAL] To see if it's
[CUSTOMER][NEUTRAL] um, we're waiting until [PII] to see if they.
[CUSTOMER][POSITIVE] So we'll give her a call right back
[CUSTOMER][NEUTRAL] OK, I'm sorry about that. Um, OK, so since he had the FMX, would he be eligible for a bite wing?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] He will be eligible for a bike wing, just not a panel.
[CUSTOMER][NEUTRAL] OK, so it, it doesn't affect the light wings.
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Let me make sure.
[CUSTOMER][POSITIVE] OK, and he's eligible for exam and cleaning as well.
[AGENT][NEUTRAL] Uh, yes, ma'am.
[CUSTOMER][NEUTRAL] No fluoride though, correct? It's in 12 months.
[AGENT][NEUTRAL] Uh, fluorides are once every 12, but I don't show a history of fluoride, just sealants, and those are once every 3 years.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And his X-ray is 80%. I'm 80% they go towards deductible.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, uh.
[AGENT][NEUTRAL] Deductible applies to everything but preventative services, which were the cleanings, bite wings, um, some exams, sealants, um, fluoride.
[CUSTOMER][NEUTRAL] Got you. OK, um, can I get your name again?
[AGENT][NEUTRAL] Yes, ma'am. It's [PII] [PII].
[CUSTOMER][NEUTRAL] And is there and is there a reference number?
[AGENT][NEUTRAL] No, ma'am. If you like, you may use my name at today's date.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Alright, you're welcome. Thanks for calling APL. Have a great day, Ms. [PII].
[CUSTOMER][NEUTRAL] You