Benefits: Reasonable and Customary charges

Reasonable and Customary (R&C) limits are designed to set a maximum allowable “reasonable” reimbursement amount for health services and major medical items based on various criteria (including submitted claims, provincial and association pricing, manufacturers’ pricing and industry data) – and these limits vary from carrier to carrier. 

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. 

To view claim eligibility and calculate out-of-pocket costs with GreenShield. You can: 

• Check your coverage online to confirm
• Ask your provider to check eligibility directly so you understand your coverage in advance  
•  Submit a pre-determination of benefits (or estimate) request to GreenShield   
• Contact GreenShield directly with any questions about coverage