UCR Fees and Balance Billing

Usual, Customary & Reasonable (UCR) is the common term for fee guidelines insurance companies use to pay claims. UCR guidelines were put in place to help control dental inflation.

It is important for you to understand what level of UCR your plan pays because it can impact the payment of your claim. If your plan pays up to the 90th percentile, this means that 90% of dentists in a given area charge that fee or less.

Geographic Differences in Fees
UCR fee levels differ from one geographic area to another. The following map shows some sample fees for a crown in different areas of the country. The figures used are at the 50th percentile.



The Fee Lookup feature will assist you by providing you with a benchmark to better understand whether your dentist's charges are reasonable.

The following information describes how UCR fee schedules and balance billing can impact your claim:

• If a dentist's fee is below the UCR level, UCR will probably not impact your claim because plans generally pay the lesser of UCR or the dentist's actual fee.
  
• If a dentist's fee exceeds the UCR level, the dentist can bill you for the difference between his or her charge and the amount allowed by the plan. This is commonly referred to as balance billing.

The examples on this page are for education only. Please refer to your dental plan summary for specific information.

The UCR fee at the 90th percentile in the following example is $800.

	Dentist Charge Below UCR	Dentist Charge Above UCR
Dentist charge for a crown	$700	$900
Less R&C 90th percentile	NA	- $100
Dentist's acceptable charge	$700	$800
Less deductible	- $50	+ $50
Covered charge	$650	$750
Co-insurance	x 50%	x 50%
Patient co-insurance	$325	$375
Patient deductible	+ $50	+ $50
Patient balance bill (for amount exceeding R&C)	NA	+ 100%
Total patient responsibility	$375	$525