Recognized charge limits

Benefits under the HealthPlus, Standard and Health+Savings Options are based on recognized charge limits.* These Options do not cover otherwise eligible expenses above recognized charge limits — they are your responsibility. For example, if you incur a $200 doctor expense, but only $180 of the charge is within recognized charge limits, only $180 will be considered an eligible expense under the plan.

Recognized charge limits do not apply to:

  • Eligible expenses provided by a network provider under the PPO Options.
  • Eligible charges from participating NAP hospitals and doctors under the OOA Options. NAP providers can be found by using BP’s custom DocFind website. (See Quick links on the LifeBenefits site.)
The recognized charge for a service or supply is the lower of:
  • What the provider bills or submits for that service or supply; and
  • The charge the claims administrator determines to be appropriate, based on factors such as the cost of providing the same or a similar service or supply and the manner in which charges for the service or supply are made, billed or coded.
    • For non-facility charges:
      • PPO Options: The 85th percentile of the Prevailing Charge Rate, for the Geographic Area where the service is furnished.
      • OOA Options: Twice the 95th percentile of the Prevailing Charge Rate, for the Geographic Area where the service is furnished.
    • For facility charges:
      • PPO Options: 150% of the Medicare Fee Schedule for the Geographic Area where the service is furnished.
      • OOA Options: Aetna uses the charge Aetna determines to be the usual charge level made for it in the Geographic Area where it was furnished.
As used above, Geographic Area and Prevailing Charge Rates are defined as follows:
  • Geographic Area: This means an expense area grouping defined by the first three digits of the U.S. Postal Service zip codes. If the volume of charges in a single three-digit zip code is sufficient to produce a statistically valid sample, an expense area is made up of a single three-digit zip code. If the volume of charges is not sufficient to produce a statistically valid sample, two or more three-digit zip codes are grouped to produce a statistically valid sample. When it is necessary to group three-digit zip codes, the grouping never crosses state lines.
  • Prevailing Charge Rates: These are rates reported by FAIR Health, a nonprofit company, in their database. FAIR Health reviews and, if necessary, changes these rates periodically. Aetna updates its systems with these changes within 180 days of receiving them from FAIR Health.
* You may be accustomed to seeing the term "reasonable and customary (R&C)," however Aetna uses the term "recognized charge." Recognized charge works in the same manner as reasonable and customary.

 

Publication date: April 2019

 

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