What are reasonable and customary limits?

Reasonable and customary (R&C) limits are the range of usual fees for comparable health care services and supplies.

Like other benefit providers, Pacific Blue Cross uses these limits to determine the maximum eligible amounts for health care services and supplies covered by your plan.

Most provider associations publish a suggested fee schedule for their practitioners. However, there is no requirement for practitioners to charge according to these schedules, and fees for like services can range (sometimes substantially).

For paramedical services, such as those provided by acupuncturists, chiropractors, massage therapists, naturopaths, physiotherapists, podiatrists, and psychologists, R&C limits may apply both per treatment and for the total number of treatments within a specific timeframe. If your plan has a contractual dollar or visit limit that is less than the R&C limit, this amount will be used to determine your reimbursement. Paramedical claims may continue to be considered as per the requirements in your contract, up to the number of visits Pacific Blue Cross considers reasonable, per year, per person. If the number of visits exceed this threshold, you will be asked to provide a note from your attending medical doctor that details the nature of illness and prognosis for future claims to be considered.

Much like provider associations, manufacturers of medical services and drugs have a manufacturer’s list price, which is the cost that the medical supplier or pharmacy pays for the product. The mark-up for these products is added at the provider’s discretion and can vary substantially.

We review R&C limits on a continual basis and make changes to ensure our allowed amounts are representative of the current standard charges in the health care environment. If your provider or supplier charges more than the allowed amount, you will be responsible for paying the difference.

Please note that exceptions and other limitations may apply under your plan. If you have questions regarding coverage, limits or a specific health care product or service, please call us at 604 419-2000 or toll-free at 1 877 PAC-BLUE. You can also sign in to your Member Profile at pac.bluecross.ca/Member.

The changing health care environment has contributed to the continuing increase in costs. As a result, governments, employers, insurers and plan members, face real challenges in continuing to fund these escalating costs. Smart shopping for health care products and services helps you by reducing out-of-pocket expenses. It also helps employers reduce plan benefit costs, which contributes to the sustainability of the benefits provided to you.

Appeals process

To file an appeal, provide us with medical documentation supporting that additional treatment or treatment by a specific provider is medically necessary. The documentation should include:

• Your diagnosis,
• The reason treatment fees exceed the R&C limits,
• Your proposed treatment plan — include how long this additional treatment will be medically required.

You can appeal the per-visit R&C limits if you have a medical condition that warrants non-standard therapy. We review each case on an individual basis. Please note that if your plan has a contractual per-visit limit, exceptions cannot be made. Also, under no circumstances can an exception be made to exceed calendar year limits.

Questions? We’re here to help. Contact us at 604 419-2000, toll-free at 1 877 PAC-BLUE or visit our website at pac.bluecross.ca.