Benefits: Administrative Guidelines including Reasonable and Customary charges

Administrative guidelines exist with insurers and benefits providers, including GreenShield, to ensure the consistent, fair, and efficient operation of the health insurance system, protecting both consumers and the stability of the industry. These guidelines regulate handling of operations, claims, and provider services, promoting sound principles and equitable practices. By following clear rules, guidelines help insurers and benefits providers meet regulatory requirements, such as those under the Canada Health Act, and ensure that health services are accessible and affordable for consumers.

These guidelines are not documented within the member benefits booklet, as the volume of them are large and are subject to change through time.

One example of an administrative guideline as of this date (i.e. September 2025) is the limit of three dental examinations (of any type) performed by a general practitioner, per person, per calendar year. Reasonable and customary (R&C) limits are another example of a common administrative guideline.

What are reasonable and customary charges?

Reasonable and Customary (R&C) limits or pricing are designed to ensure payments are not made in excess of certain dollar limits for medical equipment and services. In other words, an R&C price is the maximum amount allowed for an item or service.

GreenShield determines R&C pricing based on an annual review of:

  • Submitted amounts
  • Manufacturer’s pricing
  • Provincial and association pricing
  • Statistical industry information
  • Consultations with provider associations and the insurance community

Where a provider charges more than GreenShield’s R&C limit for a particular service/item, you will need to pay the difference out-of-pocket. The intent here is to protect you from using up large portions of your benefit maximums and, in the case of physiotherapy, massage therapy and so on, allow you to spread those dollars across multiple visits. R&C limits also prevent providers from overcharging for an eligible service/supply and impacting the sustainability of the plan. 

R&Cs in action:

Here’s an example of how R&Cs work. You have 80% coverage for massage therapy and submit a claim for $120. If GreenShield’s R&C limit for the expense is $107, you will receive 80% reimbursement on the first $107 of the claim, with the remaining $34.40 as an additional out-of-pocket expense. Where other carriers have a higher or lower R&C limit, that out-of-pocket expense would be different. 

How can you check the R&C price of a service or medical item?  

To find out more about your claim eligibility and reimbursement, prior to obtaining your service or item, you can: 

  • Submit a “mock” claim on GreenShield+
  • Submit a pre-determination of benefits (or estimate) request to GreenShield   
  • Contact the GreenShield Customer Service Centre for assistance


Contacting GreenShield:

Phone (Mon to Fri, 8:30 a.m. - 8:30 p.m. ET):

  • 1-888-525-7587, select "Option 1", or 
  • 1-888-711-1119 

Online: 

Inquiry support:

Experiencing problems with a benefit claim?

The following steps of the GreenShield Inquiry Support Model can help to resolve the problem.