AccountId: 011433970860
ContactId: f3769b39-a563-4e0a-ac2f-3cbd0559a60e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 725580 ms
Total Talk Time (AGENT): 282338 ms
Total Talk Time (CUSTOMER): 273014 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/13/f3769b39-a563-4e0a-ac2f-3cbd0559a60e_20250113T22:00_UTC.wav
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[AGENT][POSITIVE] Thank you for calling
[AGENT][NEUTRAL] Angel
[AGENT][NEUTRAL] How can I help you?
[CUSTOMER][NEUTRAL] Uh, hi there. My name is [PII] calling on behalf of the dental office on a recorded line to check the eligibility and benefit for a patient today. Could you please assist me with that?
[AGENT][POSITIVE] I can assist you with that, yes, [PII], thank you. What is your callback number if we are disconnected?
[CUSTOMER][NEUTRAL] It would be [PII], no extension.
[AGENT][NEUTRAL] Thank you. And what is the policy number please for the patients?
[CUSTOMER][NEUTRAL] OK. I have that as.
[CUSTOMER][NEUTRAL] 246-863-0.
[AGENT][NEUTRAL] OK, let me just repeat to you, [PII]. I have that as 246-863-0.
[CUSTOMER][NEUTRAL] 86, yes, 30, correct.
[AGENT][POSITIVE] OK, thank you so much. I verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] OK. I have my first name as [PII]. Date of, uh last name is [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] OK, thank you so much for the verification process and again you're calling for eligibility and benefits I can assist you with both. Um, the patient is the policy holder with an effective date of [PII].
[AGENT][NEUTRAL] And this policy shows active.
[CUSTOMER][NEUTRAL] OK. And the participation of the dentist, is it in or out of network?
[AGENT][NEUTRAL] I'm sorry, I didn't understand the question if you could repeat that for me.
[CUSTOMER][NEUTRAL] Sure. Is the dentist in or out of network?
[AGENT][NEUTRAL] This plan falls
[AGENT][NEUTRAL] Carent and PPO network and if the member is not a part of the Carrington PPO network it will then follow UCR.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] And how about the group number as well as the group name?
[AGENT][NEUTRAL] OK. The group number is 70056.
[AGENT][NEUTRAL] And the group name is M like Mike, A alpha, U uncle, M A U.
[CUSTOMER][NEUTRAL] That's it.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. Just to confirm, I have group number 7.
[CUSTOMER][NEUTRAL] 00056.
[AGENT][NEUTRAL] No, that is 70056.
[CUSTOMER][NEUTRAL] OK, too. Thank you. Is there any claims timely filing a minute?
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] No, there's no tummy filing limit to submit a claim.
[CUSTOMER][NEUTRAL] OK. Any
[CUSTOMER][NEGATIVE] So downgrade for the fillings.
[AGENT][NEUTRAL] No, there's um no downgrades on the plan and fillings are 1 per 24 months.
[CUSTOMER][NEUTRAL] And miss include class or waiting period.
[AGENT][NEGATIVE] There is a missing tooth cloth. There is no waiting period.
[CUSTOMER][NEUTRAL] OK. How about the crown? Will it be on seat date or prep date?
[AGENT][NEUTRAL] Now with this particular policy, [PII], it does not cover any major services and that includes crowns.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Coordination of benefit would be?
[AGENT][NEUTRAL] We do not coordinate benefits.
[CUSTOMER][NEUTRAL] OK. OK. And
[CUSTOMER][NEUTRAL] Just to confirm it, so, um, the coverage for this policy will be only for preventative and basic services.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. Um,
[CUSTOMER][NEUTRAL] Preventative is 100. How about basic?
[AGENT][NEUTRAL] Uh, basic is at 80.
[CUSTOMER][NEUTRAL] 80. All righty. And may I know, will the policy run on the calendar year or fiscal year?
[AGENT][NEUTRAL] Um, and calendar year.
[CUSTOMER][NEUTRAL] How about the annual max and deductible?
[AGENT][NEUTRAL] OK, and please note verification of benefits provided does not guarantee payment. The maximum is $500 and there is a $50 deductible.
[CUSTOMER][NEUTRAL] Out of the $550 saving this amount?
[AGENT][NEUTRAL] OK, just here.
[CUSTOMER][NEUTRAL] No use, ma'am yet. OK. Does preventative services apply to maximum?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. How about the deductible? Will it apply to only basic service?
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Only basic services correct.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] And for this policy will orthodontic vehicle services then.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] No, not because of the age limit, right?
[AGENT][NEUTRAL] Correct because it does not cover any major services.
[CUSTOMER][NEUTRAL] All righty. And how about endopyal and oral surgery, are they covered?
[AGENT][NEUTRAL] No, those all fall under major.
[CUSTOMER][NEUTRAL] Not covered as well. All righty. And mm scaling and route planning will not be covered as well?
[AGENT][MIXED] That is correct, not covered.
[CUSTOMER][NEUTRAL] Not covered. OK. And for this policy, how about payroll maintenance?
[AGENT][NEGATIVE] No, it is also not covered.
[CUSTOMER][NEUTRAL] [PII]. All righty.
[CUSTOMER][NEUTRAL] And may I know for the code 4346, is it covered in the basic uh preventative?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] No, it is not. I'm sorry.
[CUSTOMER][NEUTRAL] Mm. No problem. And uh may I know the co-insurance as well as the frequency for exam prophy fluoride by wings?
[AGENT][NEUTRAL] OK, for preventive services, cleanings are once every 6 months.
[AGENT][NEUTRAL] Exams are 2 for 12 month period.
[AGENT][NEUTRAL] That includes a limited
[AGENT][NEUTRAL] Fluoride is 1 for 12 month period under the age of [PII].
[AGENT][NEUTRAL] FMX and pans they share that is one per 5 year period and those are covered under basic.
[AGENT][NEUTRAL] And white wings are covered 1 per 12-month period under preventative.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] OK. Just to confirm, I have a cleaning one for 6 months, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. So, all example is your frequency.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. For the limited exam 0140, can we do any treatment on the same day with this?
[AGENT][NEUTRAL] It does not state
[CUSTOMER][NEUTRAL] OK, no problem. How about the ceiling, is it a covered services?
[AGENT][NEUTRAL] As sounds are covered, those are 1 per 36 months, permanent molar teeth only, and that are limited to dependent children under the age of [PII].
[CUSTOMER][NEUTRAL] And the preventive services for.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And just to confirm, the FMX is on basic services, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. Uh, the age limit for the fluoride is under the age of [PII].
[AGENT][NEUTRAL] Under age of [PII].
[CUSTOMER][NEUTRAL] [PII]. OK. How about the X-ray? Any
[CUSTOMER][NEUTRAL] Frequency
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] The PAs.
[AGENT][NEUTRAL] Oh, I'm so sorry. PAs have no frequency. Those are covered under basic at 80%. My apologies.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me
[CUSTOMER][POSITIVE] I thank you.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] For this policy, uh, may I know, can exact cover?
[CUSTOMER][NEUTRAL] Sorry, uh, degree authorization, is it mandatory?
[AGENT][NEGATIVE] No, it is not.
[CUSTOMER][NEUTRAL] Is there any suggested amount?
[AGENT][NEGATIVE] Uh, no.
[CUSTOMER][NEUTRAL] Non-mandatory. All righty. OK. And for this, is there any history for
[CUSTOMER][NEUTRAL] This member plan
[AGENT][NEUTRAL] Yes, there is there is history. Uh, one moment please, [PII], let me check that for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] On [PII].
[AGENT][NEUTRAL] It shows that the member had um let's see.
[AGENT][NEUTRAL] A filling um on to number 19.
[AGENT][NEUTRAL] And that is 2 surface on 2 number 19 that's again that's the filling 2392 is that code that was used.
[AGENT][NEUTRAL] Give me 1 2nd, I'm still checking for you.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] I'm almost done. I'm so sorry, um, bear with me please.
[CUSTOMER][POSITIVE] Sure, sure, no problem. Just take your time.
[AGENT][NEUTRAL] OK, thank you. On [PII], the member had an exam.
[AGENT][NEUTRAL] Um 0120.
[AGENT][NEUTRAL] Prophy 1110.
[AGENT][NEUTRAL] By wings, 0274.
[AGENT][NEUTRAL] And also, OK, and a few PAs, um, but that is it. Again on [PII], the member had an exam 0120, um, a prophy 0 1110 and by wings 0274.
[AGENT][NEUTRAL] NTAs.
[CUSTOMER][NEUTRAL] OK. No FMX, no panel history?
[AGENT][NEUTRAL] No, I'm just not show any pain or FMX history.
[CUSTOMER][NEUTRAL] All right then. Thank you very much then. So that would be all the for this if there's no other history for this number. How about the payer ID for this?
[AGENT][NEUTRAL] OK, our payer ID is 60.
[AGENT][NEUTRAL] Excuse me, 60801.
[CUSTOMER][NEUTRAL] 60801. All right. And may I know the claims timely filing limit as well?
[AGENT][NEUTRAL] There is no time assigned to submit a claim.
[CUSTOMER][NEUTRAL] I'm so sorry. I mean the billing address for that.
[AGENT][NEUTRAL] OK, I'm so sorry, yes, it is APL claims.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Just to confirm, I have [PII]. Is that correct?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] OK, thank you. And
[CUSTOMER][NEUTRAL] All right. And may I know for the code 0367 Cone Beam. Is it a covered services?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Not covered. OK, perfect. How about the reference number for this call?
[AGENT][NEUTRAL] OK, we do not provide reference numbers. [PII], please you can use my name [PII]. My last initials [PII], and today's date. Anything else I can help you with?
[CUSTOMER][POSITIVE] Uh, no, that would be all. Thank you so much for your assistance.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] You're very welcome [PII]. Thank you for calling APL. Have a great day. Thank you.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] Mm bye bye.
[AGENT][NEUTRAL] Mm bye.