Frequently Asked Questions - Provider Issues/Usual & Customary

What is Usual and Customary?
Usual and Customary is a term used to refer to the commonly charged or prevailing fees for health services within a geographic area. The geographic location is defined as the location (ZIP code area) where the service was provided. This methodology for determining allowances for medical procedures is accepted and used by most insurance companies. The entire procedure for determining U & C is designed to provide for equitable, impartial and appropriate benefit payments to the employee and the physician.

How can I know ahead of time what my network provider will charge and how much will be my responsibility? How can I know what my provider will discount from my bill?
A network provider’s contractual discounts are proprietary information they typically are not at liberty to share. However, most providers are able to give the patient a fairly accurate “itemized quote” for services to be rendered so you will able to determine what your approximate liability will be once you consider your deductible and coinsurance amounts. Like any quote for services, this is not a guarantee and may differ if the service anticipated is not actually the service performed.