UCR refers to the fee guidelines that are used to pay claims. UCR is used if you have a PPO plan but visit an out-of-network dentist.
It is important that you understand what level of UCR your plan pays, because it can affect the payment of your claim and your out-of-pocket costs. Your dental plan summary will tell you what your plan pays.
Plan Pays
If your plan pays up to the 90th percentile, this means that 90% of dentists in a given area charge that fee or less.
Example of a UCR payment
The UCR fee at the 90th percentile in the following example is $1500
| |
Dentist A charges below UCR |
Dentist B charges above UCR |
|
Dentist Charge for a Crown
|
$1,400 |
$1,600 |
|
Less: Usual, Customary and Reasonable (UCR)
|
NA |
-$100 |
|
90th Percentile
|
|
|
|
Dentist Acceptable Charge
|
$1,400 |
$1,500 |
|
Less: Deductible
|
-$50 |
-$50 |
|
Covered Charge
|
$1,350 |
$1,450 |
|
Co-Insurance Percentage
|
X50% |
X50% |
|
Patient Co-Insurance Payment
|
$675 |
$725 |
|
Patient Deductible
|
+$50 |
+$50 |
|
Patient Balance Bill for (Amount Exceeding UCR)
|
NA |
+$100 |
|
Total Patient Responsibility
|
$725 |
$875 |
Geographic differences in UCR fees
UCR fee levels differ from one state to another. The following map shows sample fees for a crown in different areas of the country. The figures used are at the 50th percentile which means that 50% of the dentists in those areas charge that amount or less for a crown.
Test your Usual, Customary and Reasonable (UCR) knowledge with this quick-to-complete quiz