oralfitnesslibrary Insurance PPO Plan Advantages Usual Customary and Reasonable UCR

Usual, Customary and Reasonable

UCR refers to the fee guidelines that are used to pay claims. UCR is used if you have a PPO plan but visit an out-of-network dentist.

It is important that you understand what level of UCR your plan pays, because it can affect the payment of your claim and your out-of-pocket costs. Your dental plan summary will tell you what your plan pays.

Plan Pays

If your plan pays up to the 90th percentile, this means that 90% of dentists in a given area charge that fee or less.

Example of a UCR payment

The UCR fee at the 90th percentile in the following example is $1500

  Dentist A charges below UCR Dentist B charges above UCR

Dentist Charge for a Crown Dentist Charge for a Crown

 $1,400 $1,600

Less: Usual, Customary and Reasonable (UCR)

 NA -$100

90th Percentile 90th Percentile

    

Dentist Acceptable Charge Dentist Acceptable Charge

 $1,400 $1,500

Less: Deductible

 -$50 -$50

Covered Charge Covered Charge

 $1,350 $1,450

Co-Insurance Percentage Co-Insurance Percentage

 X50% X50%

Patient Co-Insurance Payment Patient Co-Insurance Payment

 $675 $725

Patient Deductible Patient Deductible

 +$50 +$50

Patient Balance Bill for (Amount Exceeding UCR) Patient Balance Bill for (Amount Exceeding UCR)

 NA +$100

Total Patient Responsibility Total Patient Responsibility

 $725 $875

Geographic differences in UCR fees

UCR fee levels differ from one state to another. The following map shows sample fees for a crown in different areas of the country. The figures used are at the 50th percentile which means that 50% of the dentists in those areas charge that amount or less for a crown.

Test your Usual, Customary and Reasonable (UCR) knowledge with this quick-to-complete quiz