What Is Usual, Customary, and Reasonable (UCR) for Therapy?
UCR rates explained — how insurers use them to cap OON reimbursement, how to look up your area's rates, and what to do when the allowed amount seems too low.
2026-03-25 · 6 min read · By Emily Chen, Healthcare Billing Specialist
If you've ever received an insurance reimbursement for therapy that was lower than expected, "Usual, Customary, and Reasonable" — or UCR — may be the reason. Understanding how UCR rates work helps you set realistic expectations for what you'll get back, and in some cases, challenge a low determination.
What Does UCR Mean?
Usual, Customary, and Reasonable (UCR) is the methodology insurance companies use to determine how much they'll pay for a service provided by an out-of-network provider. Each word carries meaning:
- Usual — The fee a specific provider typically charges for a service
- Customary — What other providers with similar training charge for the same service in the same geographic area
- Reasonable — A judgment about whether the fee is consistent with standard medical practice
In practice, "UCR" has become shorthand for the database-driven "allowed amount" that insurers use to cap reimbursements for OON services. Whatever your therapist actually charges, your insurer will only reimburse based on the UCR rate for your area — which is often lower than market fees.
How UCR Rates Are Determined
Most major insurers — including Aetna, UnitedHealthcare, and BCBS — license UCR data from third-party databases. The most widely used is FAIR Health, a nonprofit that maintains a large database of billed charges by CPT code and zip code.
Insurers typically use the 50th, 70th, or 80th percentile of the FAIR Health database for a given service and region. A plan paying at the 70th percentile means it treats a claim as fully covered up to the amount that 70% of providers in your area charge — and anything above that is your responsibility.
Crucially, this data is not public, and insurers don't always disclose which percentile or which database they use. This opacity is one of the main reasons OON reimbursements are often surprising.
How UCR Affects Your Therapy Reimbursement
Here's a concrete example. Your therapist charges $200 for a 60-minute session (CPT code 90837). Your insurance plan has a $600 OON deductible and pays 70% after that. But your insurer's UCR rate for 90837 in your zip code is $155.
Once your deductible is met, your insurer pays 70% of $155 = $108.50 per session. You pay the remaining 30% of $155 ($46.50) plus the $45 gap between $155 and $200. Your net out-of-pocket per session: $91.50 — not the $60 you might have expected if you assumed reimbursement was based on your therapist's full fee.
For more on how this calculation works with your specific deductible and coinsurance, see our guide to how insurance companies calculate reimbursement.
Can You Find Out Your Plan's UCR Rate?
You can look up UCR rates for your area using the FAIR Health Consumer tool at fairhealthconsumer.org. Enter the CPT code (for example, 90837 for 60-minute individual therapy), your zip code, and whether you're insured. The tool shows the distribution of charges and the percentile breakdowns.
You can also call your insurance company's member services and ask: "What is the allowed amount for CPT code 90837 for an out-of-network provider in zip code [yours]?" They are required to provide this information under ACA transparency rules, though getting a clear answer can sometimes require persistence.
When UCR Rates Seem Unusually Low
If the UCR rate your insurer applies seems far below typical market rates, you may have grounds to challenge it. Start by:
- Looking up the FAIR Health rate for the same CPT code and zip code as a benchmark
- Requesting from your insurer the specific database and percentile they used to set the allowed amount
- Filing an appeal if you believe the rate is not consistent with actual market fees in your area
Under ACA regulations, plans must provide clear information about how OON benefits are determined. If your insurer refuses to disclose their methodology, you can file a complaint with your state insurance commissioner.
UCR and the Superbill Connection
The UCR calculation starts with the CPT code on your therapist's superbill. If the wrong CPT code is used — for example, 90832 (30-minute session) instead of 90837 (60-minute session) — your insurer will base reimbursement on the lower-value code's UCR rate. Always verify that the CPT codes on your superbill accurately reflect the length and type of your sessions.
UCR is also why two patients in different zip codes with identical plans can receive different reimbursements for the same service. Rates reflect local market conditions — a 60-minute therapy session in Manhattan carries a higher UCR rate than the same session in rural Kansas.
What You Can Do to Maximize Reimbursement
- Verify UCR rates for your area before starting therapy with an OON provider, so you can budget accurately
- Confirm that your therapist's superbills use the correct CPT codes for the actual session length and type
- Consider using HSA or FSA funds to cover the gap between the UCR rate and your therapist's full fee — pre-tax dollars make the difference more manageable
- If your OON deductible is high, time your therapy start to maximize sessions before year-end, when your deductible resets