AccountId: 011433970860
ContactId: fdf8d7bf-a2cf-451f-a0d4-233fd272a8d5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 809640 ms
Total Talk Time (AGENT): 350065 ms
Total Talk Time (CUSTOMER): 296717 ms
Interruptions: 1
Overall Sentiment: AGENT=1.3, CUSTOMER=1.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/fdf8d7bf-a2cf-451f-a0d4-233fd272a8d5_20250219T21:25_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], good afternoon. This is [PII] calling from I Smile Dental Clinic. I'm just calling to check one of our patients' eligibility and benefits. Can you help me with that?
[AGENT][POSITIVE] It would be my pleasure to assist you with the eligibility and benefits. Do you mind spelling your name for documentation?
[CUSTOMER][NEUTRAL] I'm sure that's only two letters [PII].
[AGENT][POSITIVE] Thank you [PII] and what is a good call back number please?
[CUSTOMER][NEUTRAL] Sure, this is direct. That would be [PII].
[AGENT][NEUTRAL] Thank you, [PII]. And what is the policy number for the patient, please?
[CUSTOMER][NEUTRAL] I'm sure. That would be 2259801.
[AGENT][NEUTRAL] And JD, what is the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Sure. This is for [PII]. Date of birth is [PII].
[AGENT][POSITIVE] All right, thank you. And it would be my pleasure to assist you with eligibility and benefits for [PII].
[AGENT][NEUTRAL] And I'm showing that this policy is active with the effective date of [PII].
[AGENT][NEUTRAL] And JD, I do have a fax back I can fax to you if you're interested. It will have the calendar year max deductible frequencies, limitations also our billing information.
[AGENT][NEUTRAL] And the procedures.
[CUSTOMER][NEUTRAL] Sure, if you can also send me a copy of his benefits please.
[AGENT][POSITIVE] Yes, I would be happy to. I'm working on that right now for you.
[AGENT][NEUTRAL] And also, as of right now, he has not used any of his benefits for [PII].
[CUSTOMER][POSITIVE] Thank you for that and I just have here some specific questions to ask as well regarding his benefits.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] By the way, what's the fee schedule? Are we also in or out of network?
[AGENT][NEUTRAL] This policy does not participate in a network, we paid a percentage of UCR.
[CUSTOMER][NEUTRAL] Thank you for that. How much is the patient's maximum and deductibles?
[AGENT][NEUTRAL] Now all benefits given over the phone is a verification of coverage and not a guarantee of payment. He does have a calendar year max of $1500.
[AGENT][NEUTRAL] And there is a $50 deductible. It does not apply to preventive services.
[CUSTOMER][POSITIVE] Thank you for that. How about for family?
[AGENT][NEUTRAL] And it's up to 150 per family.
[AGENT][NEUTRAL] 150 per family.
[CUSTOMER][NEUTRAL] Thank you and I just want to confirm nothing has been used yet for maximum and deductibles, right?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] For [PII], he has not used any of his benefits as of right now.
[CUSTOMER][MIXED] Thank you for that and it only applies to basic and major for the deductibles.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Thank you. How about for the home insurances for preventive basic and major?
[AGENT][NEUTRAL] Preventive is covered at 100% of UCR.
[AGENT][NEUTRAL] Basic is covered at 80 and major expenses are covered at 40%.
[CUSTOMER][POSITIVE] Thank you for that.
[CUSTOMER][NEUTRAL] And I just have some codes here. I just need to get the percentage frequency and the history.
[AGENT][NEUTRAL] How many?
[CUSTOMER][NEUTRAL] This is just for preventive services.
[AGENT][NEUTRAL] OK, how many codes do you have?
[CUSTOMER][NEUTRAL] Um, this one is just around 10. Do you want tacos or that one?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, let's do them all at once, JD. What's the, what are those codes?
[CUSTOMER][NEUTRAL] Sure. So, for exam, that would be D 0 120, D 0 150, and D0140. For prophylaxis, that would be the 111.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then for FMX and Pao D0 to 10 or D 330.
[CUSTOMER][NEUTRAL] For bye wings, 0274, and if it shares frequency with FMX.
[CUSTOMER][NEUTRAL] And then for PA 220 and D0 row 230.
[CUSTOMER][NEUTRAL] For fluoride, D 1208.
[CUSTOMER][NEUTRAL] And if you can include as well the benefit for Cance for the 1351 and for fillings if there's any downgrade only those codes, thank you.
[AGENT][NEUTRAL] OK, not a problem, JD.
[AGENT][NEUTRAL] Now the exams are 2 for 12 month period and they do share frequencies.
[AGENT][NEUTRAL] And the 0120 is under preventive.
[AGENT][NEUTRAL] At 100%.
[AGENT][NEUTRAL] As well as the 0 150.
[AGENT][NEUTRAL] 0140 is under basic services covered at 80%.
[AGENT][NEUTRAL] And let me just go ahead and check the history while I've got.
[AGENT][NEUTRAL] See if there's any history.
[AGENT][NEUTRAL] And the exams, the last exam.
[AGENT][NEUTRAL] Was on [PII], that was a 0120.
[AGENT][NEUTRAL] Also the 0150 on 2 724.
[CUSTOMER][NEUTRAL] Thank you. So for this 0 120, [PII], and for 0150, [PII], both [PII], right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Thank you and no history for D 0 140.
[AGENT][NEUTRAL] No history for 0140.
[CUSTOMER][POSITIVE] Thank you for that. And yeah, how about for prophylaxis?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that is once every 6 months, age [PII] old and older.
[AGENT][NEUTRAL] And for the prophy, the last prophy was on 226.
[AGENT][NEUTRAL] And prior to that was 8-14-23.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] 0210.
[AGENT][NEUTRAL] Um, FMX and bite wings.
[AGENT][NEUTRAL] Are once every 5 years.
[AGENT][NEUTRAL] And that is covered under basic.
[AGENT][NEUTRAL] And he does have a pano history on 27-24.
[AGENT][NEUTRAL] No
[AGENT][NEUTRAL] No, FMX history. By wings and FMX do not share history. I mean frequencies.
[CUSTOMER][NEUTRAL] Yeah, I'm sorry, what's that code again for [PII]?
[AGENT][NEUTRAL] That was a pano.
[CUSTOMER][NEUTRAL] 400 3:30.
[AGENT][NEUTRAL] Excuse me.
[AGENT][POSITIVE] Yes sir, that's correct.
[CUSTOMER][NEUTRAL] One moment here.
[CUSTOMER][NEUTRAL] And I just want to confirm that you mentioned earlier for both Byte Wings and FMX and Pao they are once every 5 years, am I correct?
[AGENT][NEUTRAL] No, the by wings are once for 12 month period. The FMX and pano are once every 5 years.
[CUSTOMER][POSITIVE] Thank you. So for by twins it's under preventive for FMX and Bao under Basic, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Thank you for that. Is there any history for byte wings?
[AGENT][NEUTRAL] By wings on 226 24.
[CUSTOMER][POSITIVE] Thank you for that. And yeah, how about for BA's?
[AGENT][NEUTRAL] Bear with me, hang on just a second if you don't mind.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] I do apologize for that, JD did not want to cough in your ear.
[CUSTOMER][NEUTRAL] Um, yeah, that's OK.
[AGENT][NEUTRAL] For the PAs, the [PII], and 30, uh, there's no frequency that is covered under basic.
[AGENT][NEGATIVE] And there's no frequency.
[AGENT][NEUTRAL] No limitations.
[CUSTOMER][POSITIVE] Thank you. How about for history?
[AGENT][NEUTRAL] Uh, history.
[AGENT][NEUTRAL] On 226 24.
[AGENT][NEUTRAL] For the 0 220 and 2:30.
[CUSTOMER][POSITIVE] Thank you for that.
[CUSTOMER][POSITIVE] Thank you. How about for fluoride, 4D 1208?
[AGENT][NEUTRAL] Mhm. Fluoride is under the age of [PII], every 12 months.
[AGENT][NEUTRAL] And no fluoride history.
[CUSTOMER][NEUTRAL] So patient is not eligible for if you're right.
[AGENT][NEUTRAL] Uh, there's no history of fluoride and it has to be under the age of [PII].
[AGENT][NEUTRAL] Every 12 months.
[CUSTOMER][POSITIVE] Thank you. And yeah, how about for Clans for the 1351?
[AGENT][NEUTRAL] Sealants are under the age of [PII], and it's once per lifetime, and that's under preventive.
[CUSTOMER][POSITIVE] Thank you. And how about for fillings?
[AGENT][NEUTRAL] The fillings are 1 per 24 months, that's for the amalgam.
[AGENT][NEUTRAL] And for the resident.
[CUSTOMER][NEGATIVE] And downgraded only to Amalgam.
[AGENT][NEGATIVE] We do not downgrade. The resin is one for 24 months and the amalgam is one for 24 months.
[CUSTOMER][NEUTRAL] So I just want to confirm for fillings, 1 for 24 months, no downgrades.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Thank you, is there any history for fillings?
[AGENT][NEUTRAL] No sir, no history.
[CUSTOMER][NEUTRAL] Thank you for that. And yeah, I think that's it for me today. Yeah, I'll just wait for the copy of the EOB as well. And yes, go ahead, I'm sorry.
[AGENT][NEUTRAL] And would you like that?
[AGENT][POSITIVE] I was just asking if you wanted that breakdown I'll be happy to send it to you. All I need is a fax number.
[CUSTOMER][NEUTRAL] Um, sure. The fax number, that would be [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And just to verify that fax number I'm sending this to 281.
[AGENT][NEUTRAL] Um, [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes, and yeah, I just want to confirm so since the patient does not have any history on file for this year, so he's eligible for all services, right? just accept the FMX Urbana.
[AGENT][NEUTRAL] Um,
[AGENT][POSITIVE] That's correct.
[CUSTOMER][POSITIVE] And bye wings, um, yeah, he's already eligible for bite wings.
[AGENT][POSITIVE] Mhm. That's correct.
[CUSTOMER][NEUTRAL] Thank you, yeah, and last thing that I need is just the group name and group number.
[AGENT][NEUTRAL] Yes, so that group number is.
[AGENT][NEUTRAL] 18528
[AGENT][NEUTRAL] And the group name is Universal Trucking.
[AGENT][NEUTRAL] United Petroleum.
[CUSTOMER][NEUTRAL] Universal Trucking United Petroleum, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Thank you and I just want to confirm is the address would be [PII]?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] And payer ID 60801, is this correct?
[AGENT][POSITIVE] Yes, sir, that is correct.
[CUSTOMER][POSITIVE] Alright, so yeah, thank you so much for your help. I'll just wait for the copy of the benefits and uh if I can just have a reference number please.
[AGENT][NEUTRAL] The reference number is my name and today's date, I spell my name [PII]
[AGENT][POSITIVE] First initial of my last name is [PII], it was a pleasure to assist you with that breakdown. The fax is on the way. You should be receiving it shortly and thank you for calling APL. I hope you have a wonderful afternoon.
[CUSTOMER][NEUTRAL] Thank you and I'm sorry, the reference number is your name and today's date, right?
[AGENT][POSITIVE] Yes, sir, that's correct.
[CUSTOMER][POSITIVE] Alright thank you so much for your help, [PII]. I'll just wait for the copy of the benefits. Have a great day and bye for now.
[AGENT][POSITIVE] Oh, thank you for calling EPL JD. You have a wonderful afternoon. Take care. Bye bye.
[CUSTOMER][POSITIVE] Thank you.