Applying Criteria for Reasonable Charge Determinations

80.8 - Applying Criteria for Reasonable Charge Determinations (Rev. 1, 10-01-03) B3-5030, B3-5030.2 The reasonable charge determination for a covered service should be based on the actual charge for the service when that charge is no higher than the applicable customary and prevailing charges. The A/B MAC (B) should exercise judgment so that its reasonable charge determinations are realistic and equitable. A/B MACs (B) should take into account special factors in individual cases that might affect the reasonableness of charges. The special factors could involve travel, medical complications, or other unusual circumstances such as prolonged time and attention required by a patient’s condition. Different services and supplies for which charges are made under Part B, may not be grouped together for the purpose of making one overall reasonable charge determination. Thus, in processing a claim for payment a separate reasonable charge determination must be made with respect to each item for which a charge is made.