Usual & Customary Fee List (dental)
The usual and customary fee list is a provincial or insurer-based schedule that outlines standard dental fees used to determine reimbursement. Insurers use this list to calculate the amount payable for each procedure, regardless of what your dentist charges.
How It Works
A usual and customary (U&C) dental fee list is a provincial- or insurer-based schedule of standard dental fees that an insurer uses to determine how much it will reimburse for each procedure, regardless of what the dentist actually charges. This reasonable and customary (R&C) limit is the maximum amount an insurance carrier will reimburse for a specific product or service, and it can vary from province to province because it is typically based on what a person without private coverage would pay for that service in their province. Each Canadian province has a dental association that publishes an annual suggested fee guide that insurers may use to set their reasonable and customary limits for dental claims. Some insurers use the provincial dental association fee guide while others use their own internal pricing schedule, and some reimburse based on a prior year's guide, so confirming which schedule a plan uses helps anticipate out-of-pocket costs. When a plan covers a stated percentage of dental costs, that percentage applies to the fee the provincial guide says the procedure should cost, not necessarily to what the dentist actually charges. If a dentist charges more than the listed fee, the plan reimburses based on the lower listed fee and the patient pays the difference. These reasonable and customary limits are used to keep essential treatments cost-effective, safeguard plans against abusive or fraudulent billing, and stabilize premiums by making plan expenses more predictable.
Example:
Alberta Blue Cross's Usual and Customary dental fees are market-determined from recent claims data of actual marketplace billings by Alberta dental offices and are calculated from an analysis of over 1,800 dental procedure codes. The U&C dental fee list is reviewed each year to provide a reasonable basis of payment, and the eligible fees are typically increased annually as dental costs rise. If your dentist charges more than the listed fee for a procedure, the plan reimburses based on the lower listed fee and you pay the difference. Because dental reimbursement is limited to what is reasonable and customary, having a dental provider submit a predetermination before treatment lets you see how much the plan will pay in advance, and most predeterminations are processed instantly.
What to Watch For:
Some insurers use the provincial dental association fee guide while others use their own internal pricing schedule, and some reimburse based on a prior year's guide, so confirming which schedule a plan uses helps anticipate out-of-pocket costs. Remember that if a dentist charges more than the listed fee, the plan reimburses based on the lower listed fee and you pay the difference. When a plan covers a stated percentage of dental costs, that percentage applies to the fee the provincial guide says the procedure should cost, not necessarily to what the dentist actually charges. Because dental reimbursement is limited to what is reasonable and customary, asking your dental provider to submit a predetermination before treatment lets you see how much the plan will pay in advance.
