Usual, Reasonable, & Customary Charge (“U&C”) means:
(i) For out-of-network providers, the normal and necessary charges submitted or made for similar services or supplies provided by other providers of medical or dental services with like experience, education and training in the same geographical area. The term “geographic area” as it applies to any particular service, medicine, or supply means a county or such greater area as is necessary to obtain a statistically representative cross-section of the level of charges. Determination of the U&C for a medicine, service, or supply shall be made by the U&C contract administrator, using the 80th percentile of all charges for the same service or supply in the geographic area based on survey data collected and maintained by the U&C contract administrator (except that the U&C for anesthesia will be a flat rate of $95 per unit in the 2023 plan year). (The “U&C contract administrator” is the entity with which the plan administrator or PPO Network has contracted to provide usual and customary rate services and access to usual and customary rate databases.)
In the event a claim is received from an out-of-network facility/provider and there is no U&C for the services provided, the claim will pay at no more than 120% of Medicare.
For unlisted CPT codes ending in “99” for which there is no U&C for the service provided and Medicare rate, the U&C will be 50% of billed charges.
In the event a claim is received for emergency services rendered outside of the United States, the billed charges will be considered the U&C for the services rendered unless the Plan Administrator or its delegate determines that the billed charges are unreasonable when compared to the charges submitted or made for similar service or supplies provided by other providers with like experience, education and training in the same country.
Notwithstanding the above, if a different rate is negotiated between an out-of-network provider/facility and the plan administrator, the PPO Network, or their delegates, then that negotiated rate will be used and will be considered the U&C for the services rendered that are submit to such different negotiated rates.
For purposes of emergency services rendered in the United States and any other services covered by the No Surprises Act, the lower of billed charges or the “qualifying payment amount” (as defined by the No Surprises Act) will be the U&C unless a different amount is negotiated per the above paragraph or unless a different amount is determined at independent dispute resolution (in which case such different amount will be the U&C).
(ii) For in-network providers, the network rate. If no network rate is in place for the service or supply, the U&C will be determined as though it was provided by an out-of-network provider.
(iii) After hours surcharges in any 24-hour facility are not U&C and will not be covered by this Plan. This applies to both in-network providers and out-of-network providers.
(iv) Note on alternative phraseology: In some Plan materials, the usual, reasonable, & customary charge may be referred to as the Usual and Customary Charge, the Usual and Customary Rate, the Reasonable and Customary Charge, the Reasonable and Customary Rate, the UCR, or some other, similar phrase.