The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called "Usual, Customary and Reasonable" (UCR).
Billing charges that insurers believe are appropriate for services throughout a region or community.
The amount that a plan considers to be the appropriate charge for a given procedure. A doctor may charge more or less than the reasonable and customary charge, but a plan will not reimburse you for charges above the reasonable and customary amount.
Also referred to as Usual and Customary. Amounts charged by health care providers that are consistent with charges from similar providers for identical or similar services in a given region.
This term refers to limiting benefit payments to fees which are reasonable and representative for the service rendered, under the circumstances rendered, by the physician rendered.
Certain health plans pay up to a reasonable and customary amount for services. This amount is based on the common fee in your geographic area for the service you receive. You are responsible for any expenses over the reasonable and customary amount.
A charge that falls within the common range of services by a majority of providers for any procedure in a given geographic region, or which is justified based on the complexity or the severity of the treatment for a specific case.
These are charges that are typical for health care services within specific regions. A fee for health care services is considered to be reasonable if it falls within the average fee for a certain service in a particular community. Generally, health plans do not cover charges in excess of R&C when members receive out-of-network care.
A payment rate based on the fees for medical services charges by health care providers in a specified area (usually a zip code or group of related zip codes).
a term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. Note: charges within a PPO network are not normally limited to reasonable and customary fees.
The charges you submit on a claim are compared with certain standards. These regularly updated standards are based on the usual fees for medical services, procedures, and supplies in your geographic area. Factors taken into consideration include the range of cost charges for the same services and supplies within your community and among communities; the doctor's degree of specialized knowledge and skill; the nature and severity of the patient's condition; and any unusual circumstances or complications. If your doctor charges you above the reasonable and customary fee, you will be responsible for that payment.
The amount charged or the amount determined to be the reasonable charge, whichever is less, for a particular Covered Service in the geographical area it is performed (same as C&R and UCR).
See Usual, Customary and Reasonable.
The maximum amount a plan or insurance contract will consider eligible for reimbursement, based upon prevailing fees in a geographic area.
a term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community. This term can also be referred to as "Prevailing Rate", "Covered Charge", "Allowable Charge" and/or "Usual" "Reasonable" and "Customary" amount.
Accepted standard costs of a medical procedure, typically based on guidelines published by the Health Insurance Association of America (HIAA). Insurance carriers usually refer to a percentage of Reasonable and Customary that they are willing to cover (you are responsible for anything beyond that amount). Also referred to as an Allowable Fee or Usual and Customary Reimbursement (UCR). Reasonable and Customary costs differ by carrier and are subject to change at any time.
