AccountId: 011433970860
ContactId: f6493edc-425f-483c-aea1-2f61989b30da
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 599900 ms
Total Talk Time (AGENT): 291249 ms
Total Talk Time (CUSTOMER): 196702 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/f6493edc-425f-483c-aea1-2f61989b30da_20250429T19:27_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from Mobile Bay Demo. I was just calling in hopes to getting um a patient's eligibility and benefits.
[AGENT][POSITIVE] Yeah, I could take eligibility and benefits for you. Uh, can I, can I get a good call back number from you first in case we're disconnected please?
[CUSTOMER][NEUTRAL] Yes ma'am, it's gonna be [PII]. There's no extension.
[AGENT][NEUTRAL] Got it. Thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes ma'am, policy number is going to be 02514855.
[AGENT][NEUTRAL] OK, and what was the name and date of birth for the member, please?
[CUSTOMER][NEUTRAL] For the member it is going to be [PII] with the date of birth of [PII].
[AGENT][NEUTRAL] Perfect, thank you for verifying that. Uh, so this policy is active. Effective date was [PII] and uh if you'd like I can send you the fax back that shows all of the covered procedures and benefit information.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Is it possible to just get it over the phone?
[AGENT][POSITIVE] Of course, yeah, I could send it to you as well though if you'd prefer.
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][POSITIVE] Yes please.
[AGENT][NEUTRAL] Sure, what was that fax number for you?
[CUSTOMER][NEUTRAL] It's gonna be [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, I'm gonna read that back to make sure I heard that correctly. That was [PII]?
[CUSTOMER][NEUTRAL] you
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, I will get that sent to you um, what kinds of questions did you have for me?
[CUSTOMER][NEUTRAL] Yes ma'am, I was just wondering for this patient what's your group number?
[AGENT][NEUTRAL] Oh yes, one moment, let me get that.
[CUSTOMER][POSITIVE] OK cool OK.
[AGENT][NEUTRAL] That group number is 20,390.
[CUSTOMER][NEUTRAL] Alrighty, and then, um, what's this patient's deductible on their max amount? Have they used remit any of it at all?
[AGENT][NEUTRAL] Sure, uh, of course I will let you know verification of coverage is not a guarantee of payment for claims. Uh, so the calendar year maximum is $1500 per covered insured. Uh, the deductible is $50 per insured, and that does not apply to preventative expenses and none has been used so far this year by any member.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Um, and then let me see, is there a missing two calls on this plan?
[AGENT][NEUTRAL] Yes there is.
[CUSTOMER][NEUTRAL] And then what's the replacement for crowns and bridges?
[AGENT][NEUTRAL] I'm so sorry, could you repeat that?
[CUSTOMER][NEUTRAL] Yes ma'am, what's the year replacement for crowns and bridges?
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Let's see, that is once every 7 years per tooth.
[CUSTOMER][NEUTRAL] Alrighty, so 7 years and then is there a waiting period on this plan?
[AGENT][NEUTRAL] Yes, um, although, well, they're not quite there to it. OK. Yeah, so it would be [PII] of this year, and that would be for all, um, major expenses, including endodontic, periodontic, oral surgery, um, preventative, basic, and radiographs do not have a waiting period.
[CUSTOMER][NEUTRAL] You said for and that was you said that the waiting period was just for major services right?
[AGENT][NEUTRAL] Correct, that would be for 12 months.
[CUSTOMER][NEUTRAL] The 12 months, yes ma'am. And then does the plan downgrade on crowns and fillings?
[AGENT][NEGATIVE] It does not.
[CUSTOMER][NEUTRAL] Alrighty and then what is the preventative basic and major cover that?
[AGENT][NEUTRAL] What was that? I'm sorry?
[CUSTOMER][NEUTRAL] They're preventative basic a major, what is that covered at?
[AGENT][NEUTRAL] Yes, preventative is at 100%. Um, this plan also just goes off of UCR, uh, so it's 100% for preventative radiographs and basic are at 80% and all major expenses are at 40%.
[CUSTOMER][NEUTRAL] Alrighty and then for simple and surgical extractions, what are those covered at?
[AGENT][NEUTRAL] Um, do you have that those codes by chance?
[CUSTOMER][NEUTRAL] Yes ma'am, um, it's gonna be 7210 and 7140 and then uh 3330, sorry.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Got it no thank you I appreciate that uh one moment.
[AGENT][NEUTRAL] OK, so 70 to 10% is under oral surgery, so that is 40%.
[AGENT][NEUTRAL] 7140 is going to be under basic so that is 80%.
[AGENT][NEUTRAL] And 3330 is endedontic, so that is uh 40%.
[CUSTOMER][NEUTRAL] Alrighty, yes ma'am, and then I do have a few other codes that I was wanting to look up as well just needing to know, um, coverages and the age limitations on it.
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yes ma'am, did you want those clothes one by one or all at once?
[AGENT][NEUTRAL] Um, what would you prefer? It's whatever is easier for you.
[CUSTOMER][POSITIVE] Oh, either way is fine, um, yeah, either way is fine with me.
[AGENT][NEUTRAL] Uh, the same here, so, um, we could just do it all at once if that's easier.
[CUSTOMER][POSITIVE] OK, well, um, my first one is, well, no, no, you're all, you're all good. It's gonna be 1351, 1354 43 41 49 1052 1160 1060 58 67 40 and 9230.
[AGENT][NEUTRAL] I'm too passive. I'm sorry.
[AGENT][NEUTRAL] 9230. OK. All righty. One moment.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, so 1351 is covered under preventative. Give me just a moment, let me look at those limitations.
[AGENT][NEUTRAL] OK, that is limited to dependent children under [PII].
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Maximum of 1 procedure per 36 months.
[AGENT][NEUTRAL] And made to permanent molars only.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. And then,
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] 1354. So 1354 is not a covered procedure under this policy.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK. 43, 41 is periodontic, so that is at 40%.
[AGENT][NEUTRAL] And that is a maximum of 1 each quadrant per 24 months.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, 49. 10 also periodontic, so that is 40%.
[AGENT][NEUTRAL] And the only limitation is a maximum of 1 procedure per 6-month period.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 5211 is under major so that is 40%.
[AGENT][NEUTRAL] Let's see, and that is maximum of 1 per 5 year period.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] 6010 is not a covered procedure.
[AGENT][NEUTRAL] Neither is 6058.
[AGENT][NEUTRAL] OK 6740 is.
[CUSTOMER][NEUTRAL] And are they not covered just due to like age limitation or are they just not covered under just the policy?
[AGENT][NEUTRAL] Not a covered procedure, right. It's just not covered under this policy.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Right, OK, and then, uh, 6740 is covered under majors at 40%, and let me take a look at those limitations.
[CUSTOMER][NEUTRAL] me
[AGENT][NEUTRAL] So maximum of 1 per 7-year period and limited to patients aged [PII] and over.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] 9230.
[AGENT][NEUTRAL] Is also under major so that is 40% and that one does not have any limitations.
[CUSTOMER][NEUTRAL] Yes ma'am. And then does this patient have any history on file at all for their paying profu by Wing? I know they haven't used any of their max deductibles.
[AGENT][NEUTRAL] Right, let me take a look this was just for uh Trinity, right?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] I have no history on file for this number at all.
[CUSTOMER][NEUTRAL] Alrighty and then what's the uh frequency for that uh pin propane by wing?
[AGENT][NEUTRAL] Oh, let me get that.
[AGENT][NEUTRAL] The preface cleaning, that is once every 6 months, uh, bite wings once per 12 month period, um, exams are 2 per 12 month period.
[CUSTOMER][NEUTRAL] Alright, yes ma'am, and then what about for that P&O?
[AGENT][NEUTRAL] Let's see, Pinos that is once every 5 years.
[CUSTOMER][POSITIVE] On every 5 years alrighty yes ma'am, and I think other than that I wanna say I should be all good thank you so much.
[AGENT][NEUTRAL] OK, sure, and once you get the facts back just so that you are aware, um, if you're looking for a specific procedure and you don't see it listed, uh, that simply means it's not going to be covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] Alrighty, yes ma'am, thank you so much and you have a
[AGENT][NEUTRAL] All righty. Would you mind spelling your name for me?
[AGENT][NEUTRAL] I'm so sorry. Would you mind spelling your name for me? No, it's OK.
[CUSTOMER][POSITIVE] Oh, I'm so sorry, yes ma'am, of course.
[CUSTOMER][NEUTRAL] Yes ma'am. It's gonna be spelled [PII]
[AGENT][POSITIVE] OK awesome I appreciate that. OK, you should be getting that fax back here in about 10 minutes or so. Um, was there anything else I could help you with?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No, ma'am. I'm all good.
[AGENT][POSITIVE] Alright, well thanks for giving us a call, [PII]. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Have a blessed one.
[AGENT][POSITIVE] Thank you. You too. Bye-bye.