This refers to the amount that a plan considers to be the appropriate charge for a given procedure. A doctor may charge more or less than the reasonable and customary charge, but a plan will not reimburse you for charges above the reasonable and customary amount.
Membership is limited to employees who live outside the network service area.
Before confinement in a hospital or treatment center, you must call the health plan. Medical professionals review information received from you and your doctor before recommending which type of facility would be best for treatment. If you do not call before admission, you are charged the preadmission certification penalty. The penalty cannot be applied to your deductible.