Usual and Customary Fee definition

Usual and Customary Fee in the EOC “Definitions” section has been changed to “Allowed Amount.” The definition applies to Tier 3 only. Allowed Amount is based on billed Charges or 160 percent of the Medicare rate, whichever is lower.  The “Services Subject to Permanente Advantage Prior Authorization Review under Tier 2 and Tier 3” and “Outpatient Laboratory, X-ray, Imaging, and Special Diagnostic Procedures” EOC sections have been modified. Bone density/DXA scans covered under Tier 2 or Tier 3 now require prior authorization by Permanente Advantage. Benefit clarifications  The “When Referrals are Required under Tier 2 and Tier 3” EOC section has been clarified. Provider referrals are not limited to physician referrals.  The EOC has been modified to clarify that we have the right to determine medical necessity.  Several sections of the EOC have been modified to clarify that when a Select Physician refers a Member to any hospital or other facility, that hospital or facility is covered under the Tier 1 benefit.  The “Post-Stabilization Care” EOC provision has been modified. We have clarified that if the Member is clinically stable and declines special transportation to a Select Provider or Select Facility (or other designated provider or facility), Post-Stabilization Care Services will be covered under Tier 2 (for Services provided by a PPO Facility or a PPO Provider) or Tier 3 (for Services provided by a Non-Participating Facility or a Non-Participating Provider). Administrative changes or clarifications  The “What You Pay” EOC section has been modified to include consistent language when describing deductible carry-over and deductible take-over provisions. The definition of Deductible in the “Definitions” EOC section has also been updated for consistency. Changes and clarifications that apply to medical benefit riders Benefit changes  The “Outpatient Prescription Drug Riders” have been changed in accordance with the Affordable Care Act. We have eliminated the Deductible (if applicable), Copayments and Coinsurance for FDA-approved contraceptive drugs and devices included on our drug formulary. Certain religious employer groups may be exempt from providing contraceptive coverage.

Usual and Customary Fee means the fee, as reasonably determined by the HMO, that is based on the fee the provider who renders the service usually charges its patients for the same service. The fee shall be within the range of usual fees other providers of similar type, training and experience in a similar geographic area charge their patients for the same service, under similar or comparable circumstances.

Usual and Customary Fee means the fee as reasonably determined by the Claim Administrator, which is based on the fee which the physician, dentist, podiatrist, psychologist, chiropractor or optometrist who renders the particular services usually charges his patients for the same service and the fee which is within the range of usual fees other physicians, den- tists, podiatrists, psychologists, chiropractors or optometrists of similar training and experience in a similar geographic area charge their patients for the same service, under similar or comparable circumstances. However, if the Claim Admin- istrator reasonably determines that the Usual and Customary Fee for a particular service is unreasonable because of exten- uating or unusual circumstances, the Usual and Customary Fee for such service shall mean the reasonable fee as reason- ably determined by the Claim Administrator.

Examples of Usual and Customary Fee in a sentence

• Usual and Customary Fee - Usual and Customary Fees are calculated by the Company based on available data resources of competitive fees in that geographic area.

• The actual charge made by a non-Network Dental Provider for a Covered Dental Service may exceed the Usual and Customary Fee.

• Non-Network Benefits are determined based on the Usual and Customary Fee for similarly situated Network Dental Providers for each Covered Dental Service.

• As a result, an Insured Person may be required to pay a non-Network Dental Provider an amount for a Covered Dental Service in excess of the Usual and Customary Fee.

• As a result, Insured Persons may be required to pay a non-Network Dental Provider an amount for a Covered Dental Service in excess of the Usual and Customary Fee.

• Insured Persons may be required to pay a non-Network Dental Provider an amount for a Covered Dental Service in excess of the Usual and Customary Fee.

• Usual and Customary Fee - Usual and Customary Fees are calculated by the Company based on available data resources of competitive fees in that geographic area.Usual and Customary Fees must not exceed the fees that the provider would charge any similarly situated payor for the same services.

• Copayment and/or Coinsurance Amount For Prescription Drug Products at a retail Network Pharmacy, Insured Persons are responsible for paying the lowest of:• The applicable Copayment and/or Coinsurance.• The Network Pharmacy’s Usual and Customary Fee for the Prescription Drug Product.• The Prescription Drug Charge for that Prescription Drug Product.

• Insured Persons may be required to pay an out-of- Network Dental Provider an amount for a Covered Dental Service in excess of the Usual and Customary Fee.

• Copayment Amount For Prescription Drug Products at a retail Network Pharmacy, Insured Persons are responsible for paying the lowest of: The applicable Copayment. The Network Pharmacy’s Usual and Customary Fee for the Prescription Drug Product. The Prescription Drug Charge for that Prescription Drug Product.

More Definitions of Usual and Customary Fee

Usual and Customary Fee means the fee, as reasonably determined by the