Definitions for "Usual, Customary and Reasonable"
Usually seen abbreviated as UCR. This is the amount that an insurance plan will pay for a doctor's visit or procedure. Generally, this is the average amount charged for services and supplies which are medically necessary, recommended by a physician, or otherwise required for treatment. See Reasonable and Customary Fees. Utilization A process to determine if one of the following is true, Is care medically necessary and appropriate? (including frequency of service and duration) Are there lower-cost forms of care available? are they efficacious? Do patients improve as a result of treatment
Commonly charged fees for health services in a certain area. The use of fee screens to determine the lowest value of provider reimbursement based on: (1) the provider's usual charge for a given procedure, (2) the amount customarily charged for the service by other providers in the area (often defined as a specific percentile of all charges in the community), and (3) the reasonable cost of services for a given patient after medical review of the case. Most health plans provide reimbursement for usual and customary charges, although no universal formula has been established for these rates.
A method used by insurance companies to establish their fee schedules. UCR uses the conversion factor method of establishing maximums; the method of reimbursement used under Medicaid B which state Medicaid programs set reimbursement rates using the Medicare method or a fee schedule, whichever is lower.
The amount allowed as a benefit for a medical expense, reduced further by deductibles, co-insurance and co-pays.