Understanding Reasonable and Customary limits
Reasonable and customary limits are the range of usual fees for comparable medical
services in a geographic area.
Like other benefit providers, Pacific Blue Cross uses these limits to determine
the maximum eligible amounts for health care services and supplies covered by your
plan.
Most provider associations publish a suggested fee schedule for their practitioners.
However, there is no requirement for them to charge according to this and fees for
like services can range (sometimes substantially).
We review Reasonable and Customary limits on a continual basis and make changes
periodically to ensure our allowed amounts are representative of the current standard
charges in the health care environment. If your provider or supplier charges more
than the allowed amount, you will be responsible for paying the difference.
In addition to Reasonable and Customary amounts, other limits may apply to your
coverage. These limits vary across every benefit plan. CARESnet will show you benefit
plan usage and eligibility providing you with information about any limits that
apply to your benefit plan.
Reduce costs by being a smart shopper
The changing health care environment has contributed to the continuing increase
in costs. As a result, governments, employers, insurers and you, the plan member,
face real challenges in continuing to fund these escalating costs. Smart shopping
for health care products and services helps you by reducing out of pocket expenses.
It also helps employers reduce plan benefit costs, which contributes to the sustainability
of the benefits provided to you.
Appeal process
You can appeal the per-visit Reasonable and Customary limits if you have a medical
condition that warrants non-standard therapy. We review each case on an individual
basis. Please note that if your plan has a contractual per-visit limit, exceptions
cannot be made to this. Also, under no circumstances can an exception be made to
exceed calendar year limits. Learn more about the appeal process.