Insurance Help
For the seriously ill and their caregivers

Usual and Customary Allowances

Most insurance policies pay benefits for the services of non-participating providers based on usual and customary allowances. Please check your policy for details.

Only the usual and customary allowances are applied to your deductible and out-of-pocket maximum.

You are responsible for paying the amount applied to your deductible, your coinsurance and the difference between what the doctor charges and the insurance company’s usual and customary allowances.

How are Usual and Customary allowances developed?

The method used varies by insurance company and the allowance varies by geographic area.  The allowances are based on claim data collected by the insurance company or data purchased from an entity which collects data.

How can I determine what my financial obligation will be for proposed services ?

If there is time you can request a predetermination of benefits from the insurance company. Most insurance companies will request a written statement from the doctor with the industry CPT codes for the proposed procedures before providing a predetermination of benefits.

1-866-NYINSHELP (1-866-694-6743)