AccountId: 011433970860
ContactId: f05ad2eb-85a1-4011-b0e8-60232550abfb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 416589 ms
Total Talk Time (AGENT): 110796 ms
Total Talk Time (CUSTOMER): 229771 ms
Interruptions: 1
Overall Sentiment: AGENT=2, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/11/f05ad2eb-85a1-4011-b0e8-60232550abfb_20250311T19:24_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] calling on behalf of the dental office to check on the eligibility and benefits of a patient on a recorded call. Could you please help me with that?
[AGENT][NEUTRAL] Yes, ma'am. I can help you. Did you say your name was [PII]?
[CUSTOMER][POSITIVE] You're right.
[AGENT][NEUTRAL] OK. And do you have a phone number I can get in case we get disconnected I can call you back.
[CUSTOMER][NEUTRAL] All right. [PII]. It's a direct line.
[AGENT][NEUTRAL] And do you have the policy number?
[CUSTOMER][NEUTRAL] All right. The member ID I have here is 024567777.
[AGENT][NEUTRAL] Thank you. Hold on one moment please.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] And the patient's name?
[CUSTOMER][NEUTRAL] It's uh [PII], uh,
[CUSTOMER][NEUTRAL] [PII]'s date of birth, [PII].
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you, [PII], and you were just needing benefits.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] You're right.
[AGENT][NEUTRAL] OK, I can help you with that. Do you want them over the phone or would you like a fax back?
[CUSTOMER][NEUTRAL] Um, OK. Uh, first off, uh, to proceed with that, may I know the fee schedule, please?
[AGENT][NEUTRAL] It's not paid on a fee schedule. It's paid by usual and customary rate.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK. UCR got it. Thank you. And uh yes, so,
[CUSTOMER][NEUTRAL] Mm, hold on.
[CUSTOMER][NEUTRAL] Why
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Thank you very much. And to confirm here, the group number, is it 70,030?
[AGENT][NEUTRAL] Hold on just a moment.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][POSITIVE] Yes, ma'am, that is correct.
[CUSTOMER][NEUTRAL] All right, got it. And then the group, is there any group name?
[AGENT][POSITIVE] Creative circle.
[CUSTOMER][POSITIVE] Creative circle. Thank you. And um
[CUSTOMER][POSITIVE] Got it. Thank you. And to check here, um,
[CUSTOMER][NEUTRAL] The effective date, is it [PII]?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] All right, great. And then, uh, is there any coordination of benefits?
[AGENT][NEUTRAL] Standard
[CUSTOMER][NEUTRAL] And the plan runs in a calendar year, [PII]?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Got it and providers in network. This is usual customary rates, so it should not make a difference, right?
[AGENT][NEUTRAL] Um, our providers go through Carrington, so it would depend on if you're a Carrington provider.
[CUSTOMER][NEUTRAL] Got it. So for the plan maximum out of the 500, may I know how much has the patient used?
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And any benefits given over the phone is not a guarantee of payment.
[AGENT][NEGATIVE] She has not used any of the benefits.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Alright, to check, uh, plan maximum is 500, deductible individual is 50, family is 150, applies to basic and major, is that correct?
[AGENT][POSITIVE] That is correct.
[AGENT][NEGATIVE] Major is not covered. Major is not covered under this policy.
[CUSTOMER][NEUTRAL] Great. And there is no.
[CUSTOMER][POSITIVE] You're right.
[CUSTOMER][NEUTRAL] You're right. So, Ortho is also not covered because ortho falls in the manger and there is no missing tooth clause or waiting period.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] All right, may I please have the co-insurance breakdown just to confirm?
[AGENT][NEUTRAL] Preventative is 100% the usual and customary and basic is 80.
[CUSTOMER][NEUTRAL] Mhm. And uh may I know what falls under the basic? I believe many are not covered.
[AGENT][NEUTRAL] Fillings and simple extractions.
[CUSTOMER][NEUTRAL] All right. Just that, just the oral surgery and the fillings.
[AGENT][NEUTRAL] No, oral surgery now, oral surgery is not covered. Only the 7140 is covered under basic.
[CUSTOMER][NEGATIVE] So endo period, all these are not.
[CUSTOMER][NEUTRAL] All right, only 71. What about uh 2393?
[AGENT][NEUTRAL] It is covered as a filling is covered, yes, ma'am.
[CUSTOMER][NEUTRAL] All right. OK, got it. So the, the only one that is covered is 7140 and uh basic uh filling.
[AGENT][NEUTRAL] Under basic
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And for the filling, is there any downgrade?
[AGENT][NEGATIVE] We do not downgrade.
[CUSTOMER][NEUTRAL] Got it. Thank you. So, uh, endo period major services, all these are not covered. To check here, I do have the benefits, uh, but to confirm, uh, for exam, is it 2 for 12 months?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] FMX shares with panel once in 5 calendar year.
[AGENT][POSITIVE] It does, and it also um combines with the 277 as well.
[CUSTOMER][POSITIVE] Got it. Thank you. For the bite wing, 0274, it is once for 12 months.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] All right. For the pro fee, it is 1 for 6 months?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Great. For fluoride, a patient is not eligible, cannot be greater than 18 once for 12 months.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And for the Cin also uh cannot be greater than 13 months in 36 months, the patient is not eligible, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Great. And you mentioned for the oral surgery, the only one that is covered is 7140. So.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] These will not be covered. So for the ones that are covered, may I know if there's any history?
[AGENT][NEUTRAL] There's no history on file.
[CUSTOMER][NEUTRAL] All right, because patient is also not used to it anything you've already provided me with the group name, group number also, so to check for the claims address, is it the [PII].
[AGENT][POSITIVE] That is correct. Uh-huh.
[CUSTOMER][NEUTRAL] Uh, and the fee schedule is UCR.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] All right, got it. Thank you very much for your help. Once again, may I please have the reference number of the call?
[AGENT][NEUTRAL] We do not have reference numbers. You can use my name in today's date.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Got it. Thank you, [PII]. Have a wonderful day. Bye for now.
[AGENT][POSITIVE] Thank you, [PII] for calling APL. You as well.
[CUSTOMER][POSITIVE] Thank you. Bye now.
[AGENT][POSITIVE] Thank you. Bye-bye.