How do dental plans set the fees for your dental work? The concept known as “usual, customary, and reasonable” fees, or UCR, is used to help set fair, market based charges. These three terms are defined as follows:
- Usual Fee: Dentists charge this fee most often for a given type of dental work.
- Customary Fee: This refers to the fee level that is set by the administrator of a dental benefit plan. It is based on actual fees that have been billed for a certain type of dental work. This is used to set the most that will be paid under a plan for that type of work.
- Reasonable Fee: This is the fee charged by a dentist for dental work that has been changed by the nature and severity of the problem that is being treated. It also takes into account any medical or dental complications or unusual circumstances. Thus, it may differ from the dentist’s “usual” fee or the plan’s “customary” fee.
The fees for indemnity plan claims are based on UCR. This type of plan pays each claim based on the amount determined to be usual, customary, and reasonable for each type of work and for each market area.
For instance, if the UCR for a cleaning in the zip code area where you live is set at $60, but you visit a dentist who charges you $90, then you would pay $30. The same rule is used when a patient with this type of plan sees a dentist who charges more than the local UCR set by the plan’s carrier.