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FAQs
What are "reasonable and customary" expenses?
Reasonable and customary (R&C) charges are the most the plan will consider for out-of-network expenses. R&C charges are based on the range of fees charged by providers with comparable training and experience for the same or similar service in a particular area. The plan pays benefits based on the R&C limit and you are responsible for any amount over the R&C limit.
For example, assume your out-of-network coinsurance rate is 70% and your provider charges you $100 for a service that the plan has determined typically costs $80 in your area (R&C equals $80). The plan would pay 70% of the $80 (that is, $56) and you would be responsible for paying 30% of the $80 (that is, $14) in addition to the difference between R&C and the charged fee (that is, $20). (Of course, the plan would not reimburse you until you had met the deductible.)
How are R&C charges determined?
UnitedHealthcare defines reasonable and customary using several pricing methodologies. The guidelines are based on the PHCS (Prevailing Healthcare Charges System), which is the largest, most comprehensive national database. The PHCS is the largest, most comprehensive national database of provider charges for private sector healthcare services and is recognized as the preeminent source of reliable, authoritative, prevailing healthcare charge data in the United States. The PHCS database collects data from more than 150 major contributors.
How can I check to see which doctors participate in the network?
You can search for doctors by visiting www.myuhc.com. If you are logged in with your user name and password, click "Physicians and Facilities" then click "Find a Physician." If you are not logged in, click "Find a Physician or Facility" and look for providers in the Choice Plus network.
How does UnitedHealthcare (UHC) know when I have reached my out-of-network deductible?
Once you reach your out-of-network deductible, subsequent services will be partially paid by coinsurance. Therefore it is important for UHC to have an accurate record of your claims. If your out-of-network provider submits claims on your behalf, UHC will have a record of those claims and will total them for you. If you pay your provider directly, you must submit your claim to UHC in order for them to have a record of your usage. When you visit www.myuhc.com and locate your specific account information, you will see the total.
When the plan pays 90% coinsurance in-network, what does that mean to me?
With 90% coinsurance, you pay 10%. For example, if an in-network service costs $100, the plan pays $90 and you pay $10. (If you participate in the Account-based Option, coinsurance is paid only after the deductible is satisfied)
When the plan pays 70% coinsurance out-of-network, what does that mean to me?
With 70% coinsurance out-of-network, the plan plays 70% of reasonable and customary charges (after the deductible has been satisfied). For example, if the provider bill is $125, of which $100 is deemed by UHC as reasonable and customary, the plan will pay 70% (or $70). You will be responsible for paying the remaining 30% ($30) for the reasonable and customary charges plus the amount above R&C ($25). In this example, the Plan pays $70 and you pay $55.
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