Reasonable and Customary Charges

August 16, 2018

 

All expenses claimed under the PSHCP are subject to reasonable and customary charges.

The term “reasonable and customary charges” (R&C) means the established maximum charge that an insurance carrier will reimburse for specific services and/or products in the province/territory where the expense is incurred. They are defined based on the amount usually charged to a person without private health care coverage. Sun Life, the Plan Administrator, determines the appropriate R&C by consulting the published fee guides for national and provincial/territorial associations of practitioners, where applicable. These maximums are continuously updated, and vary by province and territory. R&C for drug expenses are determined through the price file of the PSHCP pharmacy benefits manager, TELUS Health.

R&C limits are important to ensure claims to your benefits plan are not excessive. Therefore, smart shopping for health-care products and services helps by not only reducing your out-of-pocket expenses, but also helping to reduce benefits plan costs. They also help reduce the likelihood of benefits fraud or abuse. R&C limits are a common practice across most health care plans.

When adjudicating claims, the maximum that will be considered eligible for reimbursement will be based on the R&C in your province or territory for the service and/or product you are claiming. If the amount of your claim is higher than the established R&C, your reimbursement will be equivalent to 80% of the R&C established, not the full cost of your claim.

For example, if the R&C in the province where the service is rendered is established at $80.00 for a one-hour chiropractic treatment and you incur a charge of $100.00 for one hour, your claim will be reimbursed at 80% of $80.00 for a total of $64.00.

If you would like to know what the R&C is for a certain service and/or product before incurring an expense, call the PSHCP Call Centre at 1-888-757-7247 (toll free in North America) or in the National Capital Region at 613-247-5100, Monday to Friday from 6:30 a.m. to 8:00 p.m. EST.