Understanding Reasonable and Customary Limits

June 6, 2018

You have heard the term reasonable and customary (R&C) limits, but what are they, and how do they work? In the simplest terms, R&C limits refer to the range of typical fees for comparable services or equipment in a given geographical area.

What Are Reasonable and Customary Limits, and How Do They Work?

R&C limits refer to the maximum allowable amount that an insurance carrier will reimburse on a particular service or item. This amount usually reflects the typical cost associated with this service or product in a specific geographical region.

R&C limits are most noticeable in paramedical practitioners (chiropractor, physiotherapist, massage therapist, etc.) and medical service providers. Why? Unlike physicians and hospital services, paramedical and medical service providers do not have to adhere to a provincial fee guide, and are instead free to charge whatever they choose for their services and supplies.

Let’s use an example. Sera hurts her back, and seeks the services of a chiropractor. This particular chiropractor charges $200 for an initial consultation; however, the R&C fee for this service in Ontario is $180. When Sera submits her claim, Manulife, our insurance carrier, will use their R&C limit to determine her claim reimbursement. In this case, Sera would be reimbursed $180, and would be out of pocket the other $20.

Why are R&C limits important?
Higher rates drive higher plan costs. R&C limits are important to ensure claims to your benefits plan are not excessive. Therefore, smart shopping on your part for health-care products and services helps by not only reducing your out-of-pocket expenses, but also helping to reduce benefits plan costs. R&C limits also help reduce the likelihood of benefits fraud or abuse. Together, this means a healthier plan with more sustainable benefits.

How do I find out what my R&C limits are?
To view Manulife’s R&C amounts:

  1. Visit www.otip.com and click Log in
  2. Select Health and Dental from the drop-down menu and log in to your account
  3. After you have logged in, click My Claims
  4. Click Practitioner R&C under the My benefits quick links

Since R&C limits may change over time without notice, please review this information before starting a new medical treatment, or using a new paramedical or medical service provider. OTIP is also here to help. If you have questions about R&C limits, or how they might impact you, call OTIP at 1-866-783-6847.


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