AccountId: 011433970860
ContactId: f8b39ac4-df53-47bb-a012-8434d0f469aa
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 370679 ms
Total Talk Time (AGENT): 117318 ms
Total Talk Time (CUSTOMER): 191316 ms
Interruptions: 0
Overall Sentiment: AGENT=2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/05/f8b39ac4-df53-47bb-a012-8434d0f469aa_20250305T19:28_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] 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. Would you please help me with that? Um.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yes, I do have specific questions.
[AGENT][POSITIVE] I'll be more than happy to assist 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 [PII]. It's a direct line.
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Alright, that would be 02581028.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], um [PII].
[AGENT][NEUTRAL] Thank you, and all the information provided is a verification of benefits, not a guarantee of payment. I am showing the policy is active. It's been effective since [PII]. And what questions did you have in reference to the policy?
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] The coordination of benefit. Is there any?
[AGENT][NEUTRAL] No, there's no coordination of benefits.
[CUSTOMER][NEUTRAL] Alright, and the plan runs in the calendar year, right, [PII]?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Got it. So for this plan [PII] I mean for this calendar year, out of the 500 maximum, may I know how much has the patient used?
[AGENT][NEUTRAL] Sure, hold on one moment.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Um, so, so far for this year, they have not used any of the benefits or met the deductible.
[CUSTOMER][NEUTRAL] All right. Deductible to confirm is $50 for individual, no family deductible, right?
[AGENT][NEUTRAL] Uh, well, it's up to 150 per family, but this is an individual policy, so yes.
[CUSTOMER][NEUTRAL] Mhm. And for the deductible, does it apply to basic and major only or to all covered services?
[AGENT][NEUTRAL] Um, basic and major, but the policy does not cover major. So for this policy it's basic only.
[CUSTOMER][NEUTRAL] All right, so there will be no.
[AGENT][NEUTRAL] And the radiograph and
[CUSTOMER][NEGATIVE] Got it. There will be no or coverage since there is no major.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So, to check for the missing tooth cloths, is it satisfied?
[AGENT][NEGATIVE] There is a missing tooth cloth.
[CUSTOMER][NEUTRAL] OK, and there is no waiting period, right?
[AGENT][POSITIVE] Correct, because there's no major.
[CUSTOMER][NEUTRAL] All right, you're right. And may I please have the coinsurance breakdown just to confirm.
[AGENT][NEUTRAL] For preventative, we would cover um the policy should cover up to 100% of allowable radiographs and FMX basic and basic restorative expenses are all at 80%.
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] So basic for this would include just the basic restorative and the posterior composite.
[AGENT][NEUTRAL] I mean, there's several under basic, but
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] All right, let me, let me check with you. Endo periods, these are not covered, right?
[AGENT][NEUTRAL] Endoontic, periodontic, proteodontic, or oral surgery. Those are all under major and major is not covered by the policy.
[CUSTOMER][NEUTRAL] Got it. So these are not covered. Oral surgery is also under major. So for the posterior composite, is it downgraded?
[AGENT][POSITIVE] There's no downgrade.
[CUSTOMER][NEUTRAL] All right, and then for the um pre-authorization, it is only recommended, right?
[AGENT][NEUTRAL] Right, there's no um prior author or pre-cert required.
[CUSTOMER][NEUTRAL] And no specific amount.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Alright, so to confirm here for FMX and panel, they share frequency once in 5 years and uh it is covered under the basic 80%.
[AGENT][NEUTRAL] Right, Radiograph and FMX is kind of its own category, but yes, it's 80%.
[CUSTOMER][NEUTRAL] Got it. Exam is 2 for 12 months, by bringing one for 12 months, right?
[AGENT][POSITIVE] for 12 months. Yes, that's correct.
[CUSTOMER][NEUTRAL] Exam 2 for 12 months.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] For pro fee, it is 1 for 6 months.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] And then for the fluoride and sin patient, OK, let me check, patient is not eligible.
[AGENT][NEUTRAL] For fluoride and sealant?
[CUSTOMER][NEUTRAL] Due to the age limit. Mhm.
[CUSTOMER][NEUTRAL] Due to the each limit patient is not eligible.
[CUSTOMER][NEUTRAL] For fluoride, it is uh up to 19 once in 12 months. He's 141 in 36 months.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Mhm. Patient is. So for the ones that are covered like the exam FMX panel, by wing, prophy, may I know if there is any history for this patient?
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] That might affect frequency? All right.
[AGENT][NEUTRAL] Um, there's no history on file. We have not processed the claim for the insured yet.
[CUSTOMER][NEUTRAL] Alright then, so to check for the group name, group number is it uh Vella?
[CUSTOMER][NEUTRAL] A Terra Services LLC with the group number 770073 is the group number.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Claims address [PII].
[AGENT][POSITIVE] Tha[PII] correct.
[CUSTOMER][POSITIVE] Great. So, [PII], may I please have the fee schedule for this one?
[AGENT][NEUTRAL] Um, so this is just on a standard Carrington fee schedule?
[CUSTOMER][POSITIVE] All right, got it. Thank you very [PII]uch for your help though. Have a wonderful day and bye for now.
[AGENT][POSITIVE] You're very welcome and thanks for calling [PII]. I hope you have a great day.
[CUSTOMER][NEUTRAL] You as well. Bye now.
[AGENT][NEUTRAL] Bye bye.