What does “Reasonable and Customary” mean in relation to your health care? Why do you see this term in relation to what you are being charged for your health and dental services? According to About.com, “A reasonable and customary fee is the amount that your health plan determines is the normal range of payment for a specific health-related service or medical procedure within a given geographic area. If the charges you (or your doctor) submit to your health plan are higher than what the health plan considers normal for the covered service, then your health plan may not allow the full amount charged to you.” As this applies to NMC’s medical and dental plans, you may have to pay an additional amount based on the reasonable and customary fee. For example, if the reasonable and customary fee for a medical procedure is $150 and your doctor charges $200, you may have to pay the additional $50. Our medical plan would pay for the $150 according to whichever plan you are in and whether or not you have met your deductible, but most likely your doctor would send you a bill which includes the remaining $50 that our plan did not approve.
This is another reason that using the Priority Health network providers will benefit you. The network providers have agreed with Priority Health to pay a set amount for a specific procedure. This set amount should be at or below the reasonable and customary fee, which means you will get a discount as well as not have to pay additional costs if your doctor charges them. To find a network provider, log into your Member Account at www.priorityhealth.com and click on “Find a Doctor”.
If you have any questions about this or other NMC benefits, please contact HR at 995-1362 or 995-1025.