How does ODS determine the allowable amount for services and procedures?
ODS uses Maximum Plan Allowance (MPA) to determine the allowable amount for services and procedures. Maximum Plan Allowance (MPA) is the maximum amount that ODS will reimburse physicians and providers. For an in-network physician/provider, the maximum amount is the amount the provider has agreed to accept for a particular service. For a service by an out-of-network physician/provider, ODS will process charges for those services as follows: maximum amount is the lesser of the amount payable under any supplemental provider fee arrangements we may have in place and the seventy-fifth (75th) percentile of fees commonly charged for a given procedure in a given area, based on a national database. If a dollar value is not available in the national database, ODS will consider seventy-five (75) percent of the billed charge as MPA. The remaining twenty-five (25) percent over the MPA is the patients responsibility. In certain instances, when a dollar value is not available in the database, the cla
