What are usual, customary, and reasonable (UCR) charges?

Conventional indemnity plans operate based on usual, customary, and reasonable (UCR) charges. UCR charges mean that the charge is the provider’s usual fee for a service that does not exceed the customary fee in that geographic area, and is reasonable based on the circumstances. Instead of UCR charges, PPO plans often operate based on a negotiated (fixed) schedule of fees that recognize charges for covered services up to a negotiated fixed dollar amount.

What is a third party administrator (TPA)?

An individual or firm hired by an employer to handle claims processing, pay providers, and manage other functions related to the operation of health insurance.  The TPA is not the policyholder or the insurer.

What is a primary care physician (PCP)?

A physician who serves as a group member’s primary contact within the health plan. In a managed care plan, the primary care physician provides basic medical services,  coordinates and, if required by the plan, authorizes referrals to specialists and hospitals.