With all these factors, how much would I be reimbursed by PBC?

Below are scenarios of how a claim would be reimbursed, after factoring in the reasonable and customary limits and reimbursement levels, using the example of a massage therapist who charges $130 for an hour-long visit and the reasonable and customary limit is $126.

Scenario 1: Co-Insurance Not Met

• Submitted Amount $130.00
• R&C Eligible Limit $126.00
• Eligible Amount $126.00
• Ineligible Amount $4.00
• Reimbursement % 80%
• Co-Insurance Amount $25.20
• Plan Pays $100.80

Scenario 2: Coinsurance Met

• Submitted Amount $130.00
• R&C Eligible Limit $126.00
• Eligible Amount $126.00
• Ineligible Amount $4.00
• Reimbursement % 100%
• Co-Insurance Amount $0.00
• Plan Pays $126.00