Customary, Prevailing, and Reasonable

What is customary, prevailing, and reasonable (CPR)?

Customary, prevailing, and reasonable (CPR), sometimes referred to as usual, customary, and reasonable (UCR), is the rate that health insurance companies deem acceptable for healthcare professionals to charge for a particular service. In most health insurance plans, if the amount billed is considered CPR, the health insurance company will then pay a percentage of that fee, assuming the annual deductible has been met.

Health insurance companies determine what is considered CPR through both private and public data. The rate is generally set via location and historical trends, meaning health insurance companies want to see healthcare professionals charging fees that are roughly in line with what other healthcare professionals in the same area have been recently charging for the same or similar services.

Why is customary, prevailing, and reasonable (CPR) important in healthcare?

Some types of health insurance plans, such as preferred provider organizations (PPOs), provide at least some coverage for out-of-network services. If a patient seeks services that are out-of-network and therefore outside of a health insurance plan’s standard coverage, the health insurance company needs an efficient way to provide fair coverage. CPR allows for this process to happen in a streamlined and efficient way.

From a patient’s perspective, CPR is a safeguard against overpaying for healthcare services. Since healthcare professionals rely heavily on payments from health insurance companies, it’s essential that healthcare professionals fall within the confines of CPR—by not overcharging patients—to ensure they receive prompt and full payment from the patient’s health insurance provider.