Usual, Customary, and Reasonable (UCR) is a methodology some plans use to set an out-of-network allowance, based on prevailing charges for a service in an area. It's frequently the basis a plan cites for an out-of-network CO-45 — and, because it's a methodology rather than a fixed schedule, it's a point you can ask the plan to substantiate.
How UCR is used
For out-of-network care without a contracted rate, a plan needs some basis for what it will allow. UCR is one such basis — an estimate of the usual charge for the service in the geographic area. Different plans define and source it differently.
Disputing a UCR allowance
Because UCR is not a single published schedule, an out-of-network allowed-amount appeal can ask the plan to disclose and justify the methodology and data behind its UCR figure, rather than accepting the number at face value.
Frequently asked
Is UCR a fixed fee schedule?
Does UCR apply in-network?
Primary sources: CMS — No Surprises Act / balance-billing protections. General information, not legal or medical advice — confirm against the governing rule for the plan type.
Related guides
When the appeal has to be written, and cited
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