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 shall mean the fee, as reasonably determined by the HMO, that is based on the fee which the provider who renders the service usually charges its patients for the same service. The and the fee shall beis 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
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Examples of Usual and Customary Fee in a sentence

  • D31.01 All "Full-time" and "Part-time" Employees are entitled to benefits governed by the Usual and Customary Fee Guide.

  • The coverage, at the current rate as set by the Company’s insurance carrier’s Usual and Customary Fee Guide shall be as follows: A - Basic and Routine - 100% B - Major and Restorative - 90% C - Orthodontics - 50% Maximums: A & B combined-$4,000/person/year; C - $4,000/person/lifetime.

  • Usual and Customary Fee – The amount charged or the amount determined to be the prevailing charge, whichever is less, for a particular professional service within the geographic area in which it is performed.

  • Emergency Dental Care outside the Service Area will be reimbursed at the Usual and Customary Fee.

  • You are responsible for any balance owed after our payment of the Usual and Customary Fee and your payment of any applicable Deductible, Copayment, or Coinsurance.

  • Your insurance company may base its dollar allowance on a fee schedule (Usual and Customary Fee) which differs from current fees for our region: in these cases you will be responsible for the remaining balance.


More Definitions of Usual and Customary Fee

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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Related to Usual and Customary Fee

  • Usual and Customary Charges means those comparable charges for similar treatment, services and supplies in the geographic area where treatment is performed.

  • Usual and customary charge means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided.

  • 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 Charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness / injury involved.

  • 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.

  • Indigent Customer means the head of an indigent household:-

  • DMA Customer means a Customer of a Sponsoring Broker where representatives of the Customer that are natural persons are designated by the Sponsoring Broker to have Trading Access to the SEF Platform using the Participant ID of the Sponsoring Broker and where such Customer signs the DMA Customer Documentation.

  • Personnel Costs means the costs of researchers, technicians and other supporting staff to the extent employed on the relevant project or activity;

  • Advance Reimbursement Amounts As defined in Section 3.29 hereof.

  • Property Management Fee means the fee payable to the Manager for its day-to-day management of the Property pursuant to the Management Agreement.

  • Service Charges means the fees levied by the municipality in terms of its tariff policy for any municipal services rendered in respect of an immovable property and includes any penalties, interest or surcharges levied or imposed in terms of this policy.

  • Network Customer means an entity receiving transmission service pursuant to the terms of the Transmission Provider’s Network Integration Transmission Service under Tariff, Part III. Network External Designated Transmission Service:

  • household customer means a customer purchasing electricity for his own household consumption, excluding commercial or professional activities;

  • Information processing system means an electronic system for creating, generating, sending, receiving, storing, displaying, or processing information.

  • 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.

  • End Customer means any party that is licensed to receive the Data either directly or via a Redistributor or group of Redistributors.

  • Impact Fees means those fees imposed so that developments bear a proportionate share of the cost of public facilities and service improvements that are reasonably related to the impacts and burdens of the Project, adopted pursuant to Morgan Hill Municipal Code Chapter 3.56 and California Government Code Section 66001 et seq.

  • Proprietary Controls means easements or covenants running with the land that (a) limit land, water, or other resource use and/or provide access rights and (b) are created pursuant to common law or statutory law by an instrument that is recorded in the appropriate land records office.

  • Reimbursement Amounts As defined in Section 3.22.

  • Impact fee means a payment of money imposed under Title 11, Chapter 36a, Impact Fees Act.

  • Travel costs ’ means expenses for transportation, lodging, subsistence (meals and incidentals), and related expenses incurred by employees who are on travel status on official business of the recipient for any travel outside the country in which the organization is located. “Travel costs” do not include expenses incurred by employees who are not on official business of the recipient, such as rest and recuperation (R&R) travel offered as part of an employee’s benefits package that are consistent with the recipient’s personnel and travel policies and procedures.

  • Duties and Charges means in relation to any particular transaction or dealing all stamp and other duties, taxes, Government charges, bank charges, transfer fees, registration fees and other duties and charges in connection with the increase or decrease of the Trust Property or the creation, issue, sale, transfer, redemption or purchase of Units or the sale or purchase of Investment or in respect of the issue, transfer, cancellation or replacement of a Certificate or otherwise which may have become or may be payable in respect of or prior to or upon the occasion of the transaction or dealing in respect of which such duties and charges are payable, but do not include the remuneration payable to the Distribution Company or any Commission payable to agents on sales and redemption of Units or any Commission charges or costs which may have been taken into account in ascertaining the Net Asset Value.

  • Basic generation service transition costs means the amount by

  • Inventory control system means a system described in Section 4-41a-103.

  • Business Customer means a customer who is not a residential customer.

  • Transition Costs means the reasonable costs and expenses (including reasonable attorneys’ fees but excluding overhead) incurred or payable by the Successor Servicer in connection with the transfer of servicing (whether due to termination, resignation or otherwise), including allowable compensation of employees and overhead costs incurred or payable in connection with the transfer of the Receivable Files or any amendment to the Sale and Servicing Agreement required in connection with the transfer of servicing.