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.
A term used to refer to the commonly charged fee for a health care service within a geographic area. Insurance plans that provide coverage of a certain percentage of health care charges, such as 80%, usually only provide coverage for 80% of the UCR charge for that service.
The most commonly charged rates for medical services and supplies in a certain geographic area.
The amount customarily charged for a service or supply; most plans will only cover services up to UCR and individuals may be required to pay the full cost of the difference.
A method of deciding benefits by comparing the doctor's charges to those of other doctors in the same community and specialty.
The dollar amount a health carrier has determined to be appropriate for a particular medical service. This amount is often less than the actual charge. Each carrier determines its own UCR amount and not all health carriers use this method for determining payments.
See Allowable Amount/Charge/Cost
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.
The doctorâ€(tm)s usual fee, or a higher fee because of special circumstances (difficulty).
Charges made for Medically Necessary services or supplies essential to the care of the patient, if they are the amount normally charged by the Provider for similar services in the geographic area where the services or supplies were furnished, as determined by the Plan. Pinnacle reserves the right to make this initial determination as well as any subsequent evaluations or modifications of the Usual, Customary and Reasonable fee standard.
a term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is 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