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.
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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.
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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.
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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.

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

  • 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.


More Definitions of Usual and Customary Fee

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

  • Usual and Customary (U&C) shall mean covered expenses which are identified by the Plan Administrator, taking into consideration the fee(s) which the Provider most frequently charges the majority of patients for the service or supply, the cost to the Provider for providing the services, the prevailing range of fees charged in the same “area” by Providers of similar training and experience for the service or supply, and the Medicare reimbursement rates. The term(s) “same geographic locale” and/or “area” shall be defined as a metropolitan area, county, or such greater area as is necessary to obtain a representative cross-section of Providers, persons or organizations rendering such treatment, services, or supplies for which a specific charge is made. To be Usual and Customary, fee(s) must be in compliance with generally accepted billing practices for unbundling or multiple procedures.

  • Reasonable and Customary means, in relation to a charge for Medical Service, such level which does not exceed the general range of charges being charged by the relevant service providers in the locality where the charge is incurred for similar treatment, services or supplies to individuals with similar conditions, e.g. of the same sex and similar Age, for a similar Disability, as reasonably determined by the Company in utmost good faith. The Reasonable and Customary charges shall not in any event exceed the actual charges incurred.

  • Service Charge means the amount charged for making a service available on line and is in addition to the actual fee for a service itself. For example, one who renews a license on line will pay the license renewal fee and a service charge.