Paragon 21

Reasonable and Customary Charges

Automatically verifies whether charges exceed R&C

Reasonable and Customary charges are based upon charges of providers in the area of service. The Paragon21 Claims Modules automatically verifies whether charges being processed exceed Reasonable and Customary amounts.

Paragon21 Claims Modules supports multiple tables of Reasonable and Customary (R&C) charges. This information is accessible on-line.

Prevailing rates are determined by taking the fees for items from each geographical (State) area and then averaging out the payments made. The resulting factors are listed in sequence. A formula is used at the selected percentage and represents the prevailing factor for the item.

When charges exceed the R&C specifications, the authorised user can choose to:

	Override the R&C specifications and continue processing the claim.
	Reduce the benefits available to match the usual R&C specifications.
	Reduce the benefits available to the R&C maximum allowed.
	Round the R&C amount to a specified rounded value.
	Suspend the claim for supervisor override.