Usual and Customary definition

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.

Usual and Customary means the comparable level of charges for similar treatment, services and supplies in the geographic area where treatment, services or supplies are provided or performed.

Usual and Customary means the fee that the provider usually charges nonmedicaid customers for the same service or item. This is the maximum amount that the provider may bill the agency.

Examples of Usual and Customary in a sentence

• If the charge billed by a Non-Network Provider for any covered service is higher than the Usual and Customary fees determined by the Plan, Participants are responsible for the excess unless the Provider accepts assignment of benefits as consideration in full for services rendered.

• Additional information about the Usual and Customary Charge, including an estimate of the amount we will pay for a particular Out-of- Network Dental Service, is available upon written request.Waiting Period - means the period that must pass with respect to the individual before the individual is eligible to be Covered for benefits under the terms of this Policy.

• This shall include charges that are in excess of the Usual and Customary amount, or are for services not deemed to be Reasonable or Medically Necessary, in the Plan Administrator’s discretion and as determined by the Plan Administrator, in accordance with the Plan terms as set forth by and within this document; Experimental.

• Upon completion of an analysis, a report will be submitted to the Plan Administrator or its agent to identify the charges deemed in excess of the Usual and Customary and Reasonable amounts or other applicable provisions, as outlined in this Plan Document.

• The Plan has the discretionary authority to decide if a charge is Usual and Customary and for a Medically Necessary and Reasonable service.

More Definitions of Usual and Customary

Usual and Customary charges means the following:

Usual and Customary means the fee(s) for medical services or supplies which is (are):

Usual and Customary means the charge associated with a medical or surgical supply, service, procedure or Prescription Drug which represents the normal charge level for that procedure in the geographic area of service.

Usual and Customary means the fee regularly charged and received for a given service by a health care provider when furnishing customary treatment for a similar condition or Injury as represented by the 70th percentile of the Ingenix MDR database. We shall provide to a Covered Person, upon his written request, an estimate of the amount We will pay for a particular procedure or service. However, We will not be bound by such good faith estimate.

Usual and Customary or “U&C” means the amount a participating provider would charge to a cash paying customer for same strength, quantity, and dosage form of a covered drug, as of the date the prescription is filled.

Usual and Customary. (U&C) shall mean Covered Services which are identified by the Plan Administrator, taking into consideration the charge(s) which the provider most frequently bills the majority of patients for the service or supply, the cost to the provider for providing the service or supply, the prevailing range of charges billed in the same “area” by providers of similar training and

Usual and Customary or “U&C” means the amount a Participating Pharmacy would charge to a cash paying customer for same strength, quantity and dosage form of a covered drug, as of the date the prescription is filled.