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Usual, Customary and Reasonable (UCR) Eligible expenses are based on the usual, customary and reasonable charge incurred as a result of an injury, sickness or pregnancy for covered supplies and services received while insured under the plan. Sometimes referred to as "UCR," this charge represents the average or most common amount charged by providers for a particular service, treatment, or supply in the same geographic area. Information on rates for procedures is compiled into a nationwide data bank and updated every six months. When you submit a claim, we review the UCR rate for the service or procedure that was performed. Negotiated Fee Reimbursement PPO As with traditional PPO plans, medical care rendered by PPO providers will be reimbursed based on the negotiated fee established for that care. The negotiated fee is the amount the PPO provider has agreed to charge and reflects a discount from the PPO provider's standard charge. Once the negotiated fee has been determined, benefits will be paid at the plan's selected in-network coinsurance level. Utilization of PPO providers results in less out-of-pocket expenses incurred by the insured. PPO PLUS These plans will pay to out of network providers up to 200% if the reimbursement as would have been paid to an in network provider for the same service. Emergency Medical Care Emergency medical care rendered by PPO providers will continue to be reimbursed based on the negotiated fee established for such care. Emergency medical care rendered by non-PPO providers will be reimbursed based on the UCR level. All emergency medical care will be paid at the plan's selected out-of-network coinsurance level, unless state regulations demand otherwise. Freedom of Choice Insureds have the freedom to choose any provider at the time of service. However, insureds will have much greater out-of-pocket expenses when they use the services of a non-PPO provider. To enjoy higher levels of benefits and reduce out-of-pocket expenses, insureds are encouraged to use the services of PPO providers at all times. For additional information on High Deductible Insurance (HDHP), fill out the form on this page or contact us. |
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