AccountId: 011433970860
ContactId: e986b04b-bf81-4505-8188-ce08410b9030
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1472319 ms
Total Talk Time (AGENT): 468023 ms
Total Talk Time (CUSTOMER): 322350 ms
Interruptions: 5
Overall Sentiment: AGENT=0.4, CUSTOMER=-1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/e986b04b-bf81-4505-8188-ce08410b9030_20250429T17:29_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey, [PII], good morning. My name is [PII] and I'm calling from dental office and I have a few questions about my eligibility and benefit of my patient. Could you please help me with that?
[AGENT][POSITIVE] Yes, I'll be more than happy to help you with the eligibility and benefits. And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure. It's uh [PII]. Direct line, [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Sure. Them my member's policy number is
[CUSTOMER][NEUTRAL] 02506658.
[AGENT][NEUTRAL] Thank you for that. And you said you're calling from the provider's office?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, so I have the policy here. Can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure. The name of my patient is [PII] and the date of birth will be [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And I am showing the policy is active. It's been effective since [PII].
[CUSTOMER][NEUTRAL] And uh what about the, this patient doesn't dental benefits under this uh member ID?
[AGENT][NEUTRAL] Yes, that's the dental policy. Yes, sir. Mhm.
[CUSTOMER][NEUTRAL] And what about the network status of my provider?
[AGENT][NEUTRAL] You said the data service for your provider?
[CUSTOMER][NEUTRAL] Network status, I am asking about.
[AGENT][NEUTRAL] Say that one more time, what type of status?
[CUSTOMER][NEUTRAL] In its my provider is in network or out network under this policy.
[AGENT][NEUTRAL] This policy does not have a network. So there's a calendar year maximum deductible and percentages that will apply, um, but there's no in or out of network for this policy.
[CUSTOMER][NEUTRAL] Or any group number or group name?
[AGENT][NEUTRAL] Yes, the group number, hold on one moment.
[AGENT][NEUTRAL] Group number is 18, I'm sorry, 15844.
[CUSTOMER][NEUTRAL] No, no, no,
[AGENT][NEUTRAL] The group name is Universal Trucking.
[AGENT][NEUTRAL] Superior.
[AGENT][NEUTRAL] Bulk logistics.
[CUSTOMER][NEUTRAL] Universal Trucking Superior Bulk logistics.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Universal.
[AGENT][NEUTRAL] Trucking
[AGENT][NEUTRAL] Superior
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Bulk
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Logistics
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh as you said, this policy doesn't have any type of network status, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. So is there any out of benefits or benefits for my patient?
[AGENT][NEUTRAL] So yes, there are benefits. No, there's no out of network benefits. There's no network. The calendar year max is $1500 per person.
[AGENT][NEUTRAL] Per calendar year.
[AGENT][NEUTRAL] There's a $50 deductible.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] That does not apply to preventative services.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Preventative expenses are covered at 100% of UCR.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Radiographs and FMX.
[AGENT][NEUTRAL] Basic and basic restorative expenses are all at 80%.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Major expenses, which for us include endodontic, periodontic, prosodontic, and oral surgery, are covered at 40% with the uh 12-month waiting period.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So [PII], they'll be eligible to use their major expenses.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII] is the effective date. So [PII] will be the eligible date, right?
[AGENT][NEUTRAL] 12 months, yes. Mhm.
[CUSTOMER][NEUTRAL] OK. And uh as you said, there are no benefits. So is there any benefit because as you said, there is no network plan. So can you please double check for the networks again because I'm confused if my patient has any benefits or not.
[AGENT][NEUTRAL] There's no need to check. So a policy doesn't have to have a network. They meaning that this could be this could be their only policy or there could be others. We do not, this policy does not have a network, as in if you provide your your NPI or your provider number, we don't have a list of providers. We will process the claim as it's received and we pro we.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] would pay out or deny based on the um benefits on this policy, which we just went over, and then there's a list of covered codes here on the fax back if you need a copy, and if the codes that you're looking for are not on this list, they wouldn't be covered by this policy.
[CUSTOMER][NEUTRAL] OK. And uh I don't have any benefits copy with me, so I want to, I have some um of the codes with me. Could you just verify the insurance and the coinsurance person and frequency for me?
[AGENT][NEUTRAL] Sure. Would you like a copy of the fax back faxed to you?
[CUSTOMER][NEUTRAL] So you're not giving any benefits for this patient?
[AGENT][NEUTRAL] No, I'm giving you both. I'm asking if you'd like a copy faxed to you, sir.
[AGENT][NEUTRAL] You can still have a copy if we go over the phone.
[CUSTOMER][NEUTRAL] No, I don't want facts if you are.
[AGENT][NEUTRAL] OK, I was just asking for courtesy.
[CUSTOMER][POSITIVE] No, if you are giving the benefits, OK, no worries, no worries. Thank you so much for asking that thing.
[AGENT][NEUTRAL] May I have your list of codes? You're welcome.
[CUSTOMER][NEUTRAL] OK. All at once or one by one?
[AGENT][NEUTRAL] We can do all at once.
[CUSTOMER][NEUTRAL] Sure. Tell me whenever you are ready.
[AGENT][POSITIVE] I'm ready.
[CUSTOMER][NEUTRAL] It's 0150012001400220027203301351120811101510.
[CUSTOMER][NEUTRAL] 4341 434649104249435523912940722072140.
[CUSTOMER][NEUTRAL] 9,223,372,036,854,775,807.
[CUSTOMER][NEUTRAL] 9944
[CUSTOMER][NEUTRAL] 601061046057605829542950582127402750 and [PII].
[AGENT][NEUTRAL] Alright, is it alright if I place you on just a brief hold while I go through the codes?
[CUSTOMER][NEUTRAL] Uh, OK, sure, no worries. And before going on to hold, uh, could you please tell me if there is also covered under this policy or not?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Orthodontics is covered or not?
[AGENT][NEUTRAL] Orthodontic, did you say orthod you were speaking fast, orthodontics?
[CUSTOMER][NEUTRAL] Yes, I'm asking about, is there any or coverage? Yes, yes, or coverage.
[AGENT][NEUTRAL] Is that what you're asking?
[AGENT][NEUTRAL] Yes, orthodontic coverage is, go ahead.
[CUSTOMER][NEUTRAL] Orthodontics cover is not I'm asking.
[AGENT][NEUTRAL] Orthodontic treatment is not covered on this policy.
[CUSTOMER][POSITIVE] OK, no worries.
[CUSTOMER][NEUTRAL] And uh what about missing tooth and coordination of benefit?
[AGENT][NEUTRAL] All right, hold on one moment.
[AGENT][NEUTRAL] This policy does have a missing tooth cloth. There's no coordination of benefits, however, we received the claim, we will process it.
[CUSTOMER][POSITIVE] OK, no worries. Now, I'm waiting for the courses.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, I did it again cause it's a habit. I gotta remember to not 00 wait, but I had this up already, but still.
[AGENT][NEUTRAL] I need to open it in the browser.
[AGENT][NEUTRAL] This one is also.
[AGENT][NEUTRAL] Oh yeah anyway.
[AGENT][NEUTRAL] Open some browser.
[AGENT][NEUTRAL] Is there any history on file? So let's just get that off file oops.
[AGENT][NEUTRAL] It is fine.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes, hello?
[AGENT][POSITIVE] Thank you so much for holding. I do apologize for that wait. So there's no history on file and for code 0150120140, they're all preventative at 100%.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Frequency is 2 for 12 month period.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's also paired with uh 0180 as well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, 0220 is basic at 80%.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] 0272 is preventative at 100%, they're bite wings, so it's one bite wing per 12 months.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 0330 is radiograph FMX which is 80%.
[AGENT][NEUTRAL] And it's limited to one x-ray procedure per 5-year period.
[AGENT][NEUTRAL] Paired with 277 and 330.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 33
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] 1351.
[AGENT][NEUTRAL] It's preventative at 100%.
[AGENT][NEUTRAL] Maximum of 1 procedure for 36 months.
[CUSTOMER][NEUTRAL] OK. And age limit?
[AGENT][NEUTRAL] Applications made to permanent molar. I'm sorry?
[CUSTOMER][NEUTRAL] Mhm. Sorry, sorry. Please continue.
[AGENT][NEUTRAL] Applications made to permanent molar teeth only?
[AGENT][NEUTRAL] And limited to dependent children under age [PII]?
[AGENT][NEUTRAL] Code 1208 is not covered?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] 1110 are profi at 100%.
[AGENT][NEUTRAL] Maximum of 1 procedure per 6 months.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 1510 is preventative at 100%?
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] Limited to dependent children under age [PII].
[AGENT][NEUTRAL] And maximum of one per lifetime per quadrant or arch.
[AGENT][NEUTRAL] 4341 is major at 40%.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] 43, 46 is not covered.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 49
[CUSTOMER][NEUTRAL] And what about 43, 41, no frequency?
[AGENT][NEUTRAL] No.
[AGENT][NEGATIVE] There's no frequency.
[CUSTOMER][NEUTRAL] And all courses can be can be done on the same day?
[AGENT][NEUTRAL] Yes, there's no specification, so yes, it can be done on the same day.
[CUSTOMER][NEUTRAL] OK. Continue with 4910.
[AGENT][NEUTRAL] Major at 40%.
[AGENT][NEUTRAL] 4249, 43, 55. They're both major, 40%.
[AGENT][NEUTRAL] Maximum of 1 each quadrant per 24 months.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 2391 is basic restorative at 80%.
[AGENT][NEUTRAL] Replacement of existing only if in place for 24 months, and maximum of 1 each tooth per 24 months.
[CUSTOMER][NEUTRAL] And it is longer.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEGATIVE] And the 2391.us composers are down downgraded to amalgam.
[AGENT][POSITIVE] There's no downgrade.
[CUSTOMER][NEUTRAL] OK. Continue with 2 2940.
[AGENT][NEUTRAL] It's the same basic restorative 80% and the limitations are the same.
[AGENT][NEUTRAL] 7220 is major at 40%.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 7140 is basic at 80%.
[AGENT][NEUTRAL] Maximum of one time per tooth.
[AGENT][NEUTRAL] 7210 is major at 40%, no frequency.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 9243 is not covered?
[AGENT][NEUTRAL] 9230 is major at 40%.
[AGENT][NEUTRAL] 7953 is not covered?
[AGENT][NEUTRAL] 2930 is major at 40%.
[AGENT][NEUTRAL] Maximum of 1 per seven-year period.
[AGENT][NEUTRAL] Unlimited to dependent children under age [PII].
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] 9944601061046057 and 6058 are all not covered?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 2954 is major at 40%, maximum of 1 per seven-year period and limited to patients age [PII] and over.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] 2950 is the same.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] VI.
[AGENT][NEUTRAL] 5821.
[AGENT][NEUTRAL] Is not covered?
[AGENT][NEUTRAL] 2740 is major at 40%.
[AGENT][NEUTRAL] Max of 1 per 7-year period and limited to patients aged [PII] and over.
[AGENT][NEUTRAL] 2750 is not the same. I'm sorry.
[AGENT][NEUTRAL] And 4381 is major at 4.
[CUSTOMER][NEUTRAL] OK. And no longer on crown as well.
[AGENT][NEUTRAL] I'm sorry, continue.
[CUSTOMER][NEUTRAL] No downgrade, no downgrade on crowns as well, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] And what about 431 last code?
[AGENT][NEUTRAL] Major at 40%.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh no frequency?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And crown sir and sea of date.
[AGENT][NEUTRAL] There's no specification. It can be either or.
[CUSTOMER][NEUTRAL] OK. And you're accepting the amount of benefits, right?
[AGENT][NEUTRAL] We accept assignment of benefits. There's no coordination of benefits.
[CUSTOMER][POSITIVE] OK, no worries. Thank you so much for helping me with this patient. Kindly, I have the, may I have the reference number for this call and your name?
[AGENT][NEUTRAL] There's no
[AGENT][NEUTRAL] There's no call reference number, but you can use my name and today's date, and again, that's [PII] The first initials of my last name is [PII]. Was there anything else I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] No, thank you so much for helping me with this patient. Have a great day. Take care. Bye-bye. Enjoy your shift.
[AGENT][POSITIVE] Thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] I'm on the