AccountId: 011433970860
ContactId: f7169e08-a2f4-4782-bef8-4cfc41cd2b5e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1687560 ms
Total Talk Time (AGENT): 557809 ms
Total Talk Time (CUSTOMER): 399025 ms
Interruptions: 2
Overall Sentiment: AGENT=0, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/f7169e08-a2f4-4782-bef8-4cfc41cd2b5e_20250114T14:32_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello. Hi. My name is [PII] calling from Dental Care Alliance. Could you please help me with the eligibility and benefits for a patient?
[AGENT][POSITIVE] OK, 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 and the policy number?
[CUSTOMER][NEUTRAL] OK. The callback number would be [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, the member ID would be 02582839.
[AGENT][NEUTRAL] That was 02582839?
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, the patient's name would be [PII] and the date of birth would 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]. And what type of benefits did you want to go over today?
[CUSTOMER][NEUTRAL] OK, each subscriber is a patient, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I need a network benefits for this patient. Could you please help me with this?
[AGENT][NEUTRAL] OK, hold on one moment, I'm pulling up the benefits now.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so this policy is on the Carrington PPO network. However, if the provider is not a Carrington provider, the benefits are still the same. Did you need a copy of this fax back or did you have particular questions?
[CUSTOMER][NEUTRAL] I need my call itself. Could you please help me with this?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] I need
[CUSTOMER][NEUTRAL] All the benefits we call itself. Could you please help me with this?
[AGENT][NEUTRAL] Yes, when you say, uh, so you just want me to read the facts back to you? I, I don't, do you want me to look for certain things? OK, so the calendar year max is $500 per cover insured.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] $500 right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, and the individual deductible.
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] The deductible is up to $50 per covered insured.
[AGENT][NEUTRAL] Up to 150 per family.
[CUSTOMER][NEUTRAL] OK. May I know the coinsurance percentage for the preventive to basic and measure?
[AGENT][NEUTRAL] So the deductible does not apply to the preventative services?
[CUSTOMER][NEUTRAL] So you
[AGENT][NEUTRAL] Preventative is covered at 100%.
[AGENT][NEUTRAL] Radio graphs.
[AGENT][NEUTRAL] Basic expenses and basic restorative are all covered at 80%.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, and the major would be?
[AGENT][NEUTRAL] There's no major coverage on this policy?
[CUSTOMER][NEUTRAL] OK, may I know the group number?
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] So the group number, hold on one moment.
[AGENT][NEUTRAL] It's 70069.
[CUSTOMER][NEUTRAL] OK. Could you please let me a moment, please?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] May I know the percentage for 2740?
[AGENT][NEUTRAL] Do you have a list of codes that you'd like to give to me, and there's also other parts of the fax bag. Did you want to go through the fax back completely or you just want to go to the codes?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Codes.
[AGENT][NEUTRAL] What's the um clothes that you have?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] 01202160.
[CUSTOMER][NEUTRAL] 01400150018002100220027403304249 [PII] 1206 1351 1510 03640431434143464260.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] 29,622,740
[CUSTOMER][NEUTRAL] 675-051-10601-060593310333.
[AGENT][NEUTRAL] OK, hold on one second. So majority of these codes are major codes and major is not covered on this policy. So can we just go through the codes that are basic and preventative?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Major for us includes endodontic, periodontic, prosodontic, and oral surgery. So all of those codes from 4341.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Down, can we just do the preventative and basic because that's what's covered.
[CUSTOMER][NEUTRAL] OK. Uh, could you please help me with the 0120?
[AGENT][NEUTRAL] So 0120 is the um periodontic um oral evaluations. It's preventative at 100%. It's paired with 0140, 150, and 160.
[CUSTOMER][NEUTRAL] And the frequency would be?
[AGENT][NEUTRAL] 2
[AGENT][NEUTRAL] Just a 2nd, 2 procedures per 12-month period.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK. And for 2160?
[AGENT][NEUTRAL] 21. I'm gonna go through the list. So 2160 is basic restorative at 80%.
[AGENT][NEUTRAL] Replace existing only if in place for 24 months.
[AGENT][NEUTRAL] And let me see what the other code. Give me just one second, I'll let you know when I'm ready for the next code. There's another limitation here.
[CUSTOMER][NEUTRAL] 1 in 24 months.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The next limitation for 2160 is maximum of 1 each tooth per 24 months.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 0140. Hold on one moment, I'm going through the list. It's at basic, which is 80%.
[CUSTOMER][NEUTRAL] OK. And the frequency would be?
[AGENT][NEUTRAL] So this again is paired with 120, 150, and 160. It's two for 12 month period. So I'm not gonna go over 0150 because we just did that twice.
[CUSTOMER][NEUTRAL] OK, and for 0180?
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] 0180 is not a covered code on this list?
[CUSTOMER][NEUTRAL] OK. And 0210?
[AGENT][NEUTRAL] 0
[CUSTOMER][NEUTRAL] 7
[AGENT][NEUTRAL] So I have the list here. I'll just go down the list. Hold on one moment.
[AGENT][NEUTRAL] So 02, actually, is it alright if I place you on a brief hold while I go through these codes?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] May I place you on a brief hold while I go through the codes and get the frequency?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I'm not gonna be rushed and then miss something.
[AGENT][NEUTRAL] So we already did that, we already did that, we already did that. 0180.
[AGENT][NEUTRAL] 0180.
[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.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So code 0210 is FMX, so that's under 80%.
[AGENT][NEUTRAL] Limited to one procedure, I'm sorry, 5-year period.
[AGENT][NEUTRAL] This is also um paired with 0330.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, 1 in 5 years basic right.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] And then, um,
[AGENT][NEUTRAL] 0220 is basic at 80%. There's no frequency for that one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Bite wings are preventative 100%, um, once per 12-month period.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 1110 are the profies or cleanings, and that's once every 6 months.
[CUSTOMER][NEUTRAL] OK. Once for 6 months, is that prevented to our best.
[AGENT][NEUTRAL] For the profies, it's um that's preventative at 100%.
[CUSTOMER][NEUTRAL] OK. And for 4249?
[AGENT][NEUTRAL] Um, that's not covered.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 1206 is not covered?
[CUSTOMER][NEUTRAL] For the
[AGENT][NEUTRAL] 1351.
[AGENT][NEUTRAL] Um, it's a sealants, which is 100% preventative.
[AGENT][NEUTRAL] Um, maximum of 1 procedure per 36 months.
[CUSTOMER][NEUTRAL] OK, under the age of?
[AGENT][NEUTRAL] Limited, limited to dependent children aged [PII], under age [PII].
[AGENT][NEUTRAL] And applications made to permanent permanent molar teeth only.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 1510.
[AGENT][NEUTRAL] Um, is this space at preventative, uh, 100%?
[AGENT][NEUTRAL] Limited to dependent children under age [PII]?
[CUSTOMER][NEUTRAL] Well the same right.
[AGENT][NEUTRAL] And maximum of one per lifetime per quadrant or arch.
[CUSTOMER][NEUTRAL] Let
[CUSTOMER][NEUTRAL] I.
[AGENT][NEGATIVE] All of the clothes are not covered.
[CUSTOMER][NEUTRAL] I'm
[CUSTOMER][NEUTRAL] 0364 not code, right?
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Right, correct. All of the codes are not covered.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. Uh, shall I, uh, uh, shall I produce one by one call you say that it was not covered or covered benefit?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEGATIVE] You want me to go through each of the codes you just gave me and tell you that they're not covered?
[CUSTOMER][POSITIVE] Yes, I will.
[AGENT][NEUTRAL] 4341.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Not covered, right?
[AGENT][NEUTRAL] Correct. 4346.
[CUSTOMER][NEUTRAL] 4
[AGENT][NEUTRAL] 4260.
[CUSTOMER][NEUTRAL] 4260.
[AGENT][NEUTRAL] 4381.
[CUSTOMER][NEUTRAL] 98937.
[AGENT][NEUTRAL] 4355.
[CUSTOMER][NEUTRAL] 62.
[AGENT][NEUTRAL] 4910.
[AGENT][NEUTRAL] 2950.
[AGENT][NEUTRAL] 2962.
[CUSTOMER][NEUTRAL] 989
[AGENT][NEUTRAL] 2740.
[AGENT][NEUTRAL] 6750.
[AGENT][NEUTRAL] 5110.
[AGENT][NEUTRAL] And 6010.
[CUSTOMER][NEUTRAL] And 6059.
[AGENT][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] And 3310.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] 3310.
[AGENT][NEUTRAL] 3310 is not covered?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] OK. And for 3330?
[AGENT][NEUTRAL] 3330. Hold on one moment.
[AGENT][NEUTRAL] 3330 is not covered on this list?
[CUSTOMER][NEUTRAL] OK. And 7140?
[AGENT][NEUTRAL] OK, do you have another set of codes you'd like to give me?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] What's the next set?
[CUSTOMER][NEUTRAL] 9,223,372,036,854,775,807.
[AGENT][NEUTRAL] OK, hold on one second.
[CUSTOMER][NEUTRAL] 8080
[AGENT][NEUTRAL] So these are all major codes. These codes are not covered on this policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] There is no order, right?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Or the lifetime max.
[AGENT][NEUTRAL] Is there an auto lifetime max?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] What do you mean by that?
[CUSTOMER][NEUTRAL] The code 8080 orthodontic lifetime maximum.
[AGENT][NEGATIVE] Orthodontics not covered. So basically this policy covers preventative, basic and imaging. There is no orthodontic coverage on this policy.
[AGENT][NEUTRAL] Would you like me to fax you a copy of the fax back?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I just need a few cos itself. Uh, I just need this history and uh.
[CUSTOMER][NEUTRAL] Mailing address, group name.
[CUSTOMER][NEUTRAL] And the payer ID pre-authorization amount, is there any waiting period, original effective date, and the used amounts.
[CUSTOMER][NEUTRAL] And the history itself.
[CUSTOMER][NEUTRAL] Does the missing tooth cloth supplies or not?
[AGENT][NEGATIVE] There is a missing tooth cloth.
[AGENT][NEUTRAL] I can go through those questions again if you'll give them to me one by one. I don't remember all those questions.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But if you need the uh claims, OK, go ahead.
[CUSTOMER][NEUTRAL] for
[CUSTOMER][NEUTRAL] 42391.
[CUSTOMER][NEUTRAL] Is there any frequency or percentage?
[AGENT][NEUTRAL] 2391 is basic restorative at 80%.
[AGENT][NEUTRAL] Replace existing only if in place for 24 months?
[AGENT][NEUTRAL] A maximum of 1 each tooth per 24 months.
[CUSTOMER][NEUTRAL] OK. You said that the lifetime max would be
[CUSTOMER][NEUTRAL] $500 right?
[AGENT][NEUTRAL] I don't know what you mean by lifetime max, but the calendar year max for this policy is $500.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do periodic exams or exams share frequency with 0120140 or not?
[AGENT][NEUTRAL] 0140 again is paired with 120, 150, and 160, 2 for 12 month period.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] May I know the mailing address?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] At the same time.
[CUSTOMER][NEUTRAL] OK, may I know the group name?
[CUSTOMER][NEUTRAL] the last the last part that.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] I wasn't about that.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] The group name is A like Apple, T like Tom, C like Charlie, Healthcare Services LLC.
[CUSTOMER][NEUTRAL] OK. May I know the payer ID?
[AGENT][NEUTRAL] 60801.
[CUSTOMER][NEUTRAL] OK. May I know the insurance fee schedule?
[AGENT][NEUTRAL] This is a um Carrington fee schedule. It's, it's just a standard fee schedule.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is this a PPO plan or HMO plan or copay plan?
[AGENT][NEUTRAL] This policy is on the Carrington PPO network.
[CUSTOMER][NEUTRAL] OK. May I know the address or dollar value amount?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] We have no dollar value amount.
[AGENT][NEUTRAL] Pre-authorization or dollar value amount?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] There's no authorization required, um, and the only dollar amount is the calendar year max.
[CUSTOMER][NEUTRAL] OK. Does deductible applies to individual prevented and individual diagnostic or not?
[AGENT][NEUTRAL] It does not apply to preventative services. It applies to everything else.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, is there any waiting period?
[AGENT][NEUTRAL] Um, no, there's no waiting period because major services are not covered.
[CUSTOMER][NEUTRAL] OK. May I know the original effective date?
[AGENT][NEUTRAL] Um, this policy has been active since [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Nothing has been used in the individual deductibles and the family deductibles and the yearly max, right?
[AGENT][NEUTRAL] For [PII], I can check for you. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Um, no, none of the, uh, max has been used or the deductible has been met yet.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Are composite fillings covered on posterior teeth or not?
[AGENT][NEUTRAL] It could be um the prep or the seat date.
[CUSTOMER][NEUTRAL] No, I'm asking for the fillings. 2391.
[AGENT][NEUTRAL] Are you asking is 2391 covered?
[CUSTOMER][NEGATIVE] Downgraded or not.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, we just went over those.
[AGENT][NEUTRAL] It's under basic restorative at 80%.
[CUSTOMER][NEUTRAL] OK. I
[CUSTOMER][NEUTRAL] OK. I'm asking, does 2391 downgraded or not?
[AGENT][POSITIVE] There's no downgrades.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is 2740 downgraded or not?
[AGENT][NEUTRAL] There's no downgrades for the entire policy?
[CUSTOMER][NEUTRAL] OK, are major services paid on pre date or date?
[AGENT][NEUTRAL] It could be either or.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] It can be either or, there's no specification on the policy.
[CUSTOMER][NEUTRAL] OK. May I know the dependent age limit?
[AGENT][NEUTRAL] Depending on the cold, um.
[AGENT][NEUTRAL] Like the ones that you gave, they were under age [PII]. Some of the codes are under age [PII], so it depends on the code.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] May I know the history for 0120?
[AGENT][NEUTRAL] You said you need what for 0120?
[AGENT][NEUTRAL] I, I didn't hear you.
[CUSTOMER][NEUTRAL] History.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] History.
[AGENT][NEUTRAL] There's no history on file for 00120 for for Shelby.
[CUSTOMER][NEUTRAL] Is there any history for 0140?
[AGENT][NEUTRAL] Um, no, I'm not showing any history for that cold either, for Shelby.
[CUSTOMER][NEUTRAL] OK. And for 0150?
[AGENT][NEUTRAL] I'm not showing any for that code either.
[CUSTOMER][NEUTRAL] And for 0210?
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] I'm not showing a code for 0210.
[AGENT][NEUTRAL] Or history, sorry.
[CUSTOMER][NEUTRAL] OK. And
[CUSTOMER][NEUTRAL] And for 0274?
[AGENT][NEUTRAL] Um, not for that code either.
[CUSTOMER][NEUTRAL] OK. And for 0330?
[AGENT][NEUTRAL] I'm not showing a code for that or history for that either.
[CUSTOMER][NEUTRAL] OK. And for 10?
[AGENT][NEUTRAL] For 11:10, I'm not showing a um history for that code either.
[CUSTOMER][NEUTRAL] OK. And for 1351?
[AGENT][NEUTRAL] So we haven't processed any, we haven't processed any claims for this member, so there's no history on file.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me a moment, please.
[CUSTOMER][NEUTRAL] OK. May I have the call reference number, please?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name, which is [PII] my [PII] is [PII], and today's date.
[CUSTOMER][POSITIVE] OK. Thank you so much, [PII], and have a nice day.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You also, [PII], thanks for calling