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Usual, Customary, and Reasonable Charges

What are usual, customary, and reasonable (UCR) charges?

Usual, customary, and reasonable (UCR) charges are how much is paid for a medical service based on the cost of similar or identical medical services offered by other providers in the area. In some cases, health insurers use the UCR amount when determining the allowed amount.

The UCR charges are what is covered by health insurers for a medical service. They are considered usual, customary, and reasonable if the fee is typically charged by a doctor for a service, the cost falls within the same price range as other doctors in the area charge, and the service was deemed necessary based on the patient’s conditions.

Why are UCR charges important in healthcare?

UCR charges play a vital role in the amount of out-of-pocket fees a policyholder must pay after receiving healthcare services. For example, if a doctor charges more than what the insurance company deems usual, customary, and reasonable, the policyholder may have to pay the difference between the amount covered by the insurance company and the amount charged for the service.

UCR charges can also vary based on whether the medical provider is considered “in-network” or “out-of-network.” For instance, those who use an out-of-network provider may be responsible for some or all of the service costs.