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What does "Usual & Customary" mean?

A reimbursement primer on how usual and customary language can appear in out-of-network payment discussions.

  • Usual and customary language is tied to how a payer values a service.
  • The term may affect out-of-network reimbursement and remaining patient balance.
  • The practical question is how the plan calculated its allowed or reimbursed amount.

Ask how the amount was calculated

Usual and customary language can be confusing because it sounds simple but depends on payer methodology, plan language, service codes, and market data.

When reviewing an out-of-network bill, ask how the allowed or reimbursed amount was calculated and which plan provision applies.

Use the answer for negotiation

If the reimbursement is far below the billed charge, the calculation method can help frame the next conversation with the provider or payer.

Keep the EOB, provider bill, plan language, and any negotiation notes together.

This article is for administrative billing organization only. AdvimedPro does not provide medical, legal, insurance, or financial advice.

View original AdvimedPro article

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