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Reasonable & Customary

Reasonable and customary refers to the typical fee charged for a particular service in your geographic area. Insurers use this standard to determine how much they will reimburse for eligible expenses. If a provider charges more than the reasonable and customary rate, you must pay the difference.

This standard prevents overbilling and keeps plan costs fair for all members. Each insurer sets its own reasonable and customary fee tables, which are updated regularly to reflect local pricing trends.

Example:

If the reasonable and customary rate for a physiotherapy visit is $80 and your provider charges $100, you pay $20 in addition to any coinsurance.

What to Watch For:

Ask your provider whether their fees align with your insurer’s schedule. Repeatedly exceeding R&C limits can significantly increase out-of-pocket expenses.

Related Terms

Reimbursement / Coinsurance

Reimbursement is the amount an insurance company pays back to the insured person or directly to a healthcare provider for eligible expenses covered under a policy. Coinsurance is the portion of the cost that the insurer agrees to pay, expressed as a percentage, with the remaining balance paid by the insured. Together, these terms describe how healthcare costs are shared between you and your insurer once a claim is approved.

Claim Submission Deadline

The claim submission deadline is the final date by which an insured person must submit a claim to their insurance company for reimbursement of eligible expenses. After this date, the insurer is not obligated to pay the claim, even if the expense itself would have been covered. This deadline ensures timely processing, accurate recordkeeping, and proper financial reporting for both the insurer and the policyholder.

Provider Networks / Digital Tools

Provider networks and digital tools refer to the network of healthcare professionals, pharmacies, and service providers that partner with your insurer, along with the digital platforms that make it easier to find and use those services. A provider network helps ensure you have access to trusted practitioners who meet specific standards for pricing, credentials, and quality of care. Digital tools complement these networks by simplifying access to care and claims management through online portals, apps, or virtual services.

Claim

A claim is a formal request you or your healthcare provider submit to your insurance company to receive reimbursement or direct payment for eligible medical or dental expenses covered under your plan. Submitting a claim provides the insurer with the necessary information - such as receipts, treatment details, and provider information - to verify the service and determine the amount payable according to your policy’s terms.

Underwriting

Underwriting is the process by which an insurance company evaluates an applicant’s risk to determine whether coverage can be offered, what terms will apply, and how much the premium will cost. It involves reviewing personal, medical, occupational, and lifestyle information to assess the likelihood of future claims. The goal of underwriting is to ensure fairness by matching the cost of coverage to the level of risk presented by each applicant.

Relevant Plans

Plans that relate to Reasonable & Customary

Alberta Blue Cross - Blue Assured - Basic

Alberta Blue Cross - Blue Assured - Basic

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Enhanced

Alberta Blue Cross - Blue Assured - Enhanced

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Enhanced+

Alberta Blue Cross - Blue Assured - Enhanced+

Can apply at anytime, at any age.

Alberta Blue Cross - Blue Assured - Premium

Alberta Blue Cross - Blue Assured - Premium

Can apply at anytime, at any age.

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