Reasonable and Customary Charges

16 August 2018
This article was published before the transition to the new Plan Administrator, Canada Life. If you have any questions, contact the PSHCP Member Contact Centre at 1-855-415-4414 (toll-free anywhere in North America) or 1-431-489-4064 (call collect if you are outside North America).

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 1-888-757-7427 (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.