Reasonable & Customary

The following pages are for Providers however PruHealth members are also able to view them.

'Providers' is the term used to describe doctors and other healthcare providers that provide services to PruHealth members.

In these pages we set out our Schedule of Procedures which includes our fee maxima and rules regarding billing for multiple procedures.

PRUHEALTH SCHEDULE OF PROCEDURES

As is common with the majority of UK insurers, we've based the PruHealth Schedule of Procedures on the CCSD Schedule. This schedule was developed by the Clinical Coding & Schedule Development Group (CCSD). Originally formed in 1997, their directive was to develop a common set of codes and descriptions that could be used across the UK's private healthcare industry.

The PruHealth Schedule of Procedures contains fee maxima which we have derived from a combination of our own historical claims data and other fee schedules available in the UK.

'Fee maxima' define the upper limit of the range of specialist fees which we consider reasonable and customary for services provided in the UK private healthcare industry.

We frequently review our fee maxima and are happy to receive constructive professional feedback on relative complexities, particularly for new procedures or for procedures where there has been a significant change in the method of delivery.

MULTIPLE PROCEDURE BILLING

On the following pages we also set out guidelines on what we consider reasonable and customary billing practices for multiple procedures. We've done this to eliminate any ambiguity about such billing and prevent the inappropriate unbundling of procedures

'Unbundling' is the breaking down of a surgical procedure into components normally considered part of that procedure and charging for each component in addition.

In cases where we see inappropriate unbundling of procedures on an invoice, we will not pay for those elements of the invoice relating to any unbundled procedure.

If you have any questions on any of the information set out here please don't hesitate to contact PruHealth by emailing doctors@pruhealth.co.uk

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