Usual, Customary and Reasonable (UCR)

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 Dentist Charge for a Crown

$1,400 $1,600

Less: Usual, Customary and Reasonable (UCR) Less: Usual, Customary and Reasonable (UCR)

NA -$100

90th Percentile 90th Percentile

   

Dentist Acceptable Charge Dentist Acceptable Charge

$1,400 $1,500

Less: Deductible Less: Deductible

-$50 -$50

Covered Charge Covered Charge

$1,350 $1,450

Co-Insurance Percentage Co-Insurance Percentage

X50% X50%

Patient Co-Insurance Payment Patient Co-Insurance Payment

$675 $725

Patient Deductible Patient Deductible

+$50 +$50

Patient Balance Bill for (Amount Exceeding UCR) Patient Balance Bill for (Amount Exceeding UCR)

NA +$100

Total Patient Responsibility 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