Understanding Reasonable and Customary Limits

Wednesday, October 09, 2013
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Insurance Basics, Understanding plan limits / exclusions

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.

Starting January 1, 2017, the length of treatment (in minutes) for physiotherapy and massage must be indicated on your receipt when submitting. It’s important to ask your practitioner to specify the length of treatment on your receipt to receive the correct reimbursement for your claim.

Receipts and online claims submitted without the length of treatment will be reimbursed based on a 20 minute physiotherapy session and a 30 minute massage therapy session.

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.

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