Oscar Health
Provider Manual
Individual & Family Plans and Small
Group Plans
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Table of Contents
Introduction 7
Overview 7
Our Philosophy 8
Resources 8
Our Products Referenced in this Manual 8
Our Service Areas 9
Using Oscar for Providers 9
Our Providers 10
Overview 10
Provider Training 10
Provider Requirements 10
Provider Insurance Requirements 11
Compliance with the Americans with Disabilities Act (ADA) 11
Language Assistance for Limited English Proficiency (LEP) 12
Oscar's Commitment to Cultural Competency 12
Confidentiality and Protected Health Information (PHI) 13
Provider Disputes 13
Our Network 14
Network Overview 14
Our Delegated Vendors 14
Our Members 15
A Better Member Experience 15
Member’s Rights and Responsibilities 15
Designation of an Authorized Representative 16
Enrollment 16
Overview 16
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Members on Individual & Family Plans 16
Members on Employer-Sponsored Small Group Plans 16
Open Enrollment Period 17
Special Enrollment Period 17
Grace Periods 17
Eligibility 18
Verifying Eligibility 18
Member ID Cards 18
Verifying Benefits 20
Newborn Eligibility 20
Plan Design Details 20
Overview 20
Diabetes Care Plan 20
Claims and Payment 20
Overview 20
Claims Submission 21
Timely Filing of Claims 21
Requests for Additional Information 22
Guidelines for Additional Information 22
Medical Record Content 22
Itemized Bill Content 22
Timely Processing of Claims 23
Enrolling in ACH & ERA 23
Incomplete Claims 24
Claim Denials 24
Claim Corrections and Late Charges 24
Claims for Emergency Services 25
Collection of Cost Share 25
Provider Inquiry 26
Coordination of Benefits (COB) 26
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When Oscar is not primary payor 26
Workers’ Compensation 27
Reimbursement Requirements and Policies 27
Balance Billing Reimbursement 27
Interim Billing 27
Interest Payments 27
Interest on Late Payments 27
Interest on Underpayments 27
Good Faith Payments 28
Reimbursement Policies 28
Claims Overpayment 28
Utilization Management 29
Overview 29
Authorization Request Requirements 29
Authorization Request Communication 30
Same or Similar Specialty Review 30
Clinical Criteria 31
Program Staff 32
Services Requiring Authorization 34
Failure to Preauthorize 34
Emergency, Urgent, and Ambulance Services 34
Post-Stabilization 35
Second Medical Opinion Coverage 35
Second Cancer Opinion 35
Second Surgical Opinion 35
Required Second Surgical Opinion 35
Experimental and Investigational Treatments 35
Delegation and Oversight 36
Monitoring and Reporting of Utilization Management 36
Peer-to-Peer Process 36
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Audits 37
Claims Payment Audits 37
Credentialing 38
Overview 38
Practitioner Rights 38
Practitioner Obligations 39
Credentialing Delegation and Oversight 39
Non-Discrimination Policy 39
Re-credentialing Process for Practitioners 39
Grievances and Appeals 40
Grievances 40
Appeals 40
Access to Care 41
Overview 41
Availability Standards 42
Referrals 42
Authorizing an Out-of-Network Provider 42
Continuity and Transition of Care 42
Fraud, Waste, and Abuse 43
Overview 43
Detection 43
Prevention and Investigation 43
Resolution 44
Reporting Fraud, Waste, and Abuse 44
Quality and Population Health Management 45
Overview 45
Quality and Performance Improvement 45
Preventive Health and Wellness Initiatives 46
Population Health Management 47
Oscar Livongo Diabetes Program 47
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Health Management and Education 47
Member and Provider Satisfaction 48
Potential Quality Issues 48
Definitions 48
Process 48
Reporting 49
Clinical Practice and Preventive Health Guidelines 49
Overview 49
Preventive Care Guidelines 50
Acute / Chronic Medical Condition Guidelines 50
Behavioral Health Guidelines 51
Medical Records and Standards 51
Medical Record Content 51
Pharmacy Services 52
Overview 52
Formulary Management 52
Prior Authorizations and Non-Formulary Exceptions 53
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Introduction
Overview
Welcome to Oscar Health, Inc. and its affiliate insurers (collectively, “Oscar”). We think health
insurance should be smart, simple, and friendly. That’s why we built Oscar, and we’re so glad to
be working with you. Our goal is to change the way providers and consumers interact with
healthcare by using technology, design, and data. This document includes useful information
regarding our health plans, including topics such as claims and prior authorizations as well as
contact information. This Manual is meant to be read in conjunction with State Specific
Supplements, which are available on our website (www.hioscar.com/providers/resources).
This Manual is effective January 1, 2022 and applies to covered services you provide to our
members or the members through our benefit plans insured by or receiving administrative
services from us, unless otherwise noted. This Manual is subject to change; the content is
updated periodically to better support our health care provider networks.
Terms and definitions as used in this guide:
● “Oscar” refers to Oscar Health, Inc. and its affiliate insurers.
● “Member” refers to a person eligible and enrolled to receive coverage from Oscar for
covered services.
● “Subscriber” refers to the person who is responsible for a contract with a health insurance
plan.
● “Enrollee” refers to anyone covered under the health insurance contract.
● “You,” “Your” or “Provider” refers to any health care provider subject to this Manual.
● “Us,” “We” or “Our” refers to Oscar.
● “Provider Manual” or “Manual” refers to this document, which should be read in
conjunction with State Specific Supplement(s) in the state(s) in which you service Oscar
members.
● “Provider Portal” refers to Oscar’s dedicated online platform for providers
(www.provider.hioscar.com).
● “Your Agreement,” “Provider Agreement” or “Agreement” refers to your Participation
Agreement with Oscar.
● “Covered Services” refers to services that Oscar members are entitled to receive via
benefits of their qualified health plan.
Please note that should any conflict exist between this Provider Manual and your Agreement’s
state program requirements, your Agreement’s state program requirements will control for those
benefit plans covered by that regulatory exhibit. In addition, should any conflict exist between
your agreement and this Provider Manual, your agreement will control unless the Provider Manual
contains specific Oscar benefit plan administrative and clinical requirements applicable to
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services provided to an Oscar member. Any failure to follow specific benefit plan requirements set
forth in this Provider Manual may result in either a delay or denial of payment.
If you ever have questions, please do not hesitate to reach out to us. We look forward to working
together!
Our Philosophy
Great health insurance starts with a great network. We’re partnering with forward-thinking
providers and world-class health systems to change healthcare for the better. We want to make it
simple for you to manage your practice so that you can focus on providing care. And - we’re here
when you need us.
Resources
Welcome to the Oscar family. Questions? We’re here to help.
Resource
Contact / Access Information
Provider Services, Member Services,
and other general information
1-855-OSCAR-55 (1-855-672-2755)
● Provider Services Hours: Mon-Fri,
8:00am-6:00pm (local time across markets)
● Member Service Hours: Mon-Fri,
8:00am-8:00pm (local time across markets);
Sat-Sun, 8:00am-8:00pm California only
Utilization Management
1-855-OSCAR-55 (1-855-672-2755)
● Utilization Management Hours: Mon-Fri,
8:30am-5:00pm (local time across markets)
Oscar’s Website
www.hioscar.com
Oscar’s Provider Portal
www.provider.hioscar.com
State Specific Provider Resources
See State Specific Supplements:
www.hioscar.com/providers/resources
Forms
www.hioscar.com/forms
Policies
www.provider.hioscar.com/resources
Our Products Referenced in this Manual
Oscar qualified health plans subject to this Manual:
Product Type
Plan Type
Applicable States
Individual & Family Plan
EPO
CA, CO, FL, IA, KS, MO,
MI, NE, NJ, NY, TX, TN,
VA
HMO*
AZ, GA, NC, OH, PA
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PPO
AR, OK
Small Group
EPO
NJ, NY
PPO
NJ
*Note: You can access our Illinois HMO plan Provider Manual here: www.hioscar.com/providers/resources.
Our Service Areas
States where Oscar sells the above qualified health plans applicable to this Manual, include: AR,
AZ, CA, CO, FL, GA, IA, KS, MO, MI, NC, NE, NJ, NY, OH, OK, PA, TX, TN, and VA. Each State
Specific Supplement lists the counties within each state that Oscar services.
Using Oscar for Providers
You can use Oscar’s Provider Resources site (www.hioscar.com/providers/resources) and
Provider Portal (www.provider.hioscar.com) to find everything you need to work with Oscar. We
built these sites to simplify your team’s workflows so that you can focus on delivering great care
to members.
Go to www.hioscar.com/providers to:
● Request to join the network
● Browse resources such as:
o Provider Manuals for all markets
o Policies (clinical guidelines, reimbursement policies, etc.) and forms
o Tutorials and how-to-guides on using the Provider Portal
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● Search our provider directory for in-network specialists, lab facilities and more
● Search our drug formulary to find out what medications Oscar covers
Create a Provider Portal account to complete the following tasks online:
● Check member eligibility
● Check status of claims
● Submit prior authorizations electronically
● Sign up for electronic payments
● Review members’ clinical information
● Connect your staff to your organization (practice) account and grant permission to
complete tasks in the Portal
Our Providers
Overview
We’re so glad to have you in our network! To help make working with Oscar simple, we have
created this Provider Manual with direction and guidance around the basic operational processes
of providers and provider organizations. Please note that provider organizations are responsible
for distributing copies of this Provider Manual to their in-network providers.
Provider Training
All contracted providers and provider organizations are required to provide appropriate training for
employees and applicable subcontractors within 90 days of hire and annually. Such training shall
cover compliance programs that may include, but are not limited to, Fraud, Waste, and Abuse
(FWA), Potential Quality Issues (PQI), and the Health Insurance Portability and Accountability Act
(HIPAA).
Provider Requirements
Where applicable, and in addition to those requirements in the Provider’s Participation Agreement,
you must agree to permit Oscar or appropriate regulatory bodies, as required, to conduct on-site
evaluations periodically in accordance with the current state and federal laws and regulations and
to comply with recommendations, if any. You and your applicable facility must give Oscar, HHS,
the GAO, any Peer Review Organization (PRO) or accrediting organizations, their designees, and
other representatives of regulatory or accrediting organizations the right to audit, evaluate, or
inspect books, contracts, medical records, patient care documentation, other records or
contractors, subcontractors, or related entities for services provided on behalf of Oscar during the
term of the Participation Agreement, and, also, for the time period required by applicable law
following the termination of the Participation Agreement or the completion of an audit, whichever
is later.
You must provide covered services according to the terms of your Participation Agreement,
consistent with Oscar’s policies and procedures as mentioned in the Participation Agreement and
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this Provider Manual, and within the professional standards of practice for care generally
recognized within the health care community in which you operate.
As an Oscar provider, you must treat all Oscar members equally and may not refuse to provide
covered services unless you are unable to provide such services according to the terms of your
Participation Agreement. You are expected to provide covered services to Oscar members in the
same manner, in accordance with the same standards, and with the same time availability, as
provided to your other patients.
Please note that your Participation Agreement requires you to refer Oscar members to other
in-network contracted physicians, hospitals, and other providers and facilities. Exceptions to
in-network referrals shall be made for emergency services that cannot be provided by in-network
providers and those set forth in the Participation Agreement or the Provider Manual, and those
approved by Oscar.
The following may be grounds for a provider’s termination from Oscar's network:
● No admitting privileges to an in-network hospital; providers are required to report if they
lose their admitting privileges and must show best efforts to regain them
● Admitting members to out-of-network hospitals
● Performing procedures at out-of-network facilities
● Referrals to out-of-network providers (including laboratories)
Provider Insurance Requirements
Throughout the term of your Participation Agreement, you and your providers must maintain a
malpractice, general liability, and any other insurance and bond in the amounts usual and
customary for covered services provided with a licensed managed care company admitted to do
business in the state and acceptable to Oscar. In the event that providers procure a “claims
made” policy as distinguished from an occurrence policy, providers must procure and maintain
prior to termination of such insurance, continuing “tail” coverage or any other insurance for a
period of not less than five (5) years following such termination. See State Specific Supplements
for information on notification timelines regarding any reduction or cancelation of professional
liability and malpractice insurance coverage.
Upon request, you will provide to Oscar, within five (5) business days from the date of service (or
any shorter timeframe as required by law), notice of any member lawsuit alleging malpractice.
Compliance with the Americans with Disabilities Act (ADA)
Oscar employees, business partners and contracted providers must comply with ADA
requirements, including compliance with Section 504 of the Rehabilitation Act which requires that
electronic and information technology be accessible to people with disabilities and special needs.
Web pages, portals and other electronic forms of communication are compliant with these
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standards. Any documents provided on member-based portals are compliant with the Section
504 standards allowing the use of assistive reading programs.
Please contact Oscar’s Provider Services department toll free at 1-855-OSCAR-55 with any
comments or questions about content and accessibility.
Language Assistance for Limited English Proficiency (LEP)
Oscar assesses the linguistic needs of its enrollee population to ensure members have access to
translation and interpretation services for medical services, customer service, and health plan
administrative documentation, as needed and according to state regulations. Oscar also ensures
member access to translated or alternative format documents and communication as necessary,
including for the visually and hearing impaired.
Members requiring interpreter services can contact Oscar’s Member Services department at
1-855-OSCAR-55 to access, free of charge, Oscar's language services.
Delegated providers are required to follow the policies and procedures established by Oscar to
ensure those members with limited English proficiency receive appropriate interpretative and
translation services.
Oscar's Commitment to Cultural Competency
Cultural competency in healthcare is the ability of providers to provide culturally competent care,
understanding the social, ethnic, religious, and linguistic characteristics and needs of our
members. Oscar is committed to ensuring that our members are treated with dignity and respect
and that their cultural needs are considered when interacting with providers.
What cultural competency means for our members: Socio-cultural differences between
members and healthcare professionals influence many aspects of the medical encounter that can
impact patient satisfaction, adherence to medical advice, and health outcomes. For example,
members respond better when care instructions are delivered in their own language. Moreover,
knowledge of, and sensitivity to, cultural issues can impact the way members communicate their
medical needs, and how physicians and nurses can enhance diagnosis and treatment. Cultural
education for providers can not only accomplish the goal of culturally sensitive care, but can also
help address ethnic disparities in healthcare.
Cultural competency resources: Oscar strives to offer providers the resources they need to
deliver high-quality, culturally sensitive services. This eLearning (which can be found at
https://thinkculturalhealth.hhs.gov/education) is offered by the U.S. Department of Health and
Human Services free of charge and equips providers with the necessary competencies to
improve the quality of treatment for our diverse member population. We encourage our providers
to utilize this training to learn more about how to improve their interaction with members who
have specific language or ethnic preferences.
Language Assistance Program: Oscar operates a Language Assistance Program that
recognizes the cultural and language diversity of our member population and these differences.
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This language service is provided through TransPerfect. If you have questions about how to use
the language service or general questions about Oscar’s approach to cultural competency,
please call 1-855-OSCAR-55.
Confidentiality and Protected Health Information (PHI)
Oscar and its providers are considered “Covered Entities” under the Privacy Rule, implemented
pursuant to HIPAA, and must comply with the strictest applicable federal and state standards for
the use and disclosure of PHI. Oscar and its providers are required by federal and state laws to
protect a member’s PHI and are also required to report any breaches pursuant to federal and
state laws. Oscar maintains physical, administrative, and technical security measures to
safeguard PHI; it is important that any provider and its delegated entities maintain these
safeguards of PHI as well. To discuss any known or suspected breaches of the privacy of our
members, please immediately contact our HIPAA Privacy Officer at privacyrequest@hioscar.com.
Please utilize encrypted email if the content includes PHI.
Provider Disputes
Oscar defines a dispute as a contracted provider’s written notice to Oscar or to Oscar’s capitated
provider:
● Challenging, appealing or requesting reconsideration of a claim (or a bundled group of
substantially similar multiple claims that are individually numbered) that has been denied,
adjusted or contested
● Seeking resolution of a billing determination or other contract dispute (or a bundled group
of substantially similar multiple billing or other contractual disputes that are individually
numbered)
● Disputing a request for reimbursement of an overpayment of a claim.
For payment dispute submissions: A provider wishing to submit a payment dispute may do so
using Oscar’s Dispute Resolution Form (copies of Oscar's Dispute Resolution Form, by state, can
be found at www.provider.hioscar.com/resources) submitted by mail, through Oscar’s electronic
provider portal, or via fax. Submission of this form will trigger Oscar’s Dispute Resolution Process.
Please see below for methods of submission:
Electronic Provider Portal Submission:
www.provider.hioscar.com
Fax:
1-888-977-2062
By mail:
Oscar Health, Inc.
P.O. Box 52146
Phoenix AZ, 85072–2146
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For inquiries about an administrative process (as distinct from a payment dispute): Providers
should call Oscar’s Provider Services (1-855-OSCAR-55).
Oscar abides by all state and federal regulations related to surprise billing.
Our Network
Network Overview
In certain markets, Oscar may operate multiple provider networks in the same service area.
Providers can confirm their in-network status via provider directories on Oscar’s website
(www.hioscar.com/care-options). More information on Oscar’s network choices can be found in
your State Specific Supplement. A members’ chosen network, if applicable, will be listed on the
member’s ID card. Providers should make best efforts to refer to other providers that participate in
the member’s specific network.
Our Delegated Vendors
See below for a list of our nationally delegated vendors.
Service
Partner
Contact Information
Behavioral Health and
Substance Abuse Services
Optum
Electronic Payor ID:
87726
Claims Submission Address:
Optum
P.O. Box 30757
Salt Lake City, UT 84130-0757
Prescriptions / Specialty
Pharmacy Claims
CVS/Caremark
Claims Submission Address:
CVS/Caremark Claims Department
PO Box 52136
Phoenix, AZ 85072-2136
Pediatric Dental
LIBERTY Dental
Electronic Payor ID:
CX083
Claims Submission Address:
LIBERTY Dental Plan
Attn: Claims Department
P.O. Box 26110
Santa Ana, CA 92799-6110
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Transplants
Please send transplant claims to
the contracted vendor for the
particular member.
Cigna LifeSource
Claims Submission Address:
Cigna LifeSource NAC Claims
P.O. Box 3539
Scranton, PA 18505
Optum Health
Electronic Payor ID:
41194
Claims Submission Address:
Optum Complex Medical Claims (CMC)
P.O. Box 30758
Salt Lake City, UT 84130
For delegated prior authorization and pediatric vision services, Oscar engages with the network
partners listed in our State Specific Supplements. Providers of these services must be in the
respective partner’s networks, and claims must be submitted to the address listed. The network
partners listed in our State Specific Supplements also handle contracting, credentialing, and, in
some instances, utilization management and review for these services. For more information on
the vendors Oscar uses for utilization management and reviews, please see the Utilization
Management section of this manual.
Our Members
A Better Member Experience
In addition to great benefits, Oscar’s unique experience offers individuals and families no cost
virtual care options, support from Care Guides and market differentiating digital tools such as the
Member Portal and mobile application.
Member’s Rights and Responsibilities
Oscar ensures the following rights and responsibilities for Oscar members:
● Receive information about the member rights and responsibilities
● The right to the privacy of medical records and personal health information
● A right to receive information about Oscar, its services, its practitioners and providers and
member rights and responsibilities; for more information please see our website at
www.hioscar.com or call Member Services at 1-855-OSCAR-55
● A right to be treated with respect and recognition of their dignity and their right to privacy
by all providers, practitioners, Oscar-contracted vendors and Oscar staff
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● A right to participate with practitioners and providers in making decisions about their
healthcare
● A right to a candid discussion with their practitioners and providers of appropriate or
medically necessary treatment options for their conditions, regardless of cost or benefit
coverage
● A right to voice grievances or appeals about Oscar and its contracted providers and
practitioners regarding the care or services they provide. Please refer to the “Grievances
and Appeals” section of this Manual for directions on how to assist a member in
submitting a grievance or appeal
● A right to make recommendations regarding Oscar’s member rights and responsibilities
policy
● A responsibility to supply information (to the extent possible) that Oscar and its
practitioners and providers need in order to provide care
● A responsibility to follow plans and instructions for care that they have agreed to with their
practitioners
● A responsibility to understand their health problems and participate in developing mutually
agreed-upon treatment goals, to the degree possible
● A responsibility to pay the appropriate coinsurance, copay, or cost share in accordance
with their Oscar plan
Designation of an Authorized Representative
Members have the right to designate an Authorized Representative. If they wish to do so, they
must complete and sign an Authorized Representative form, found on: www.hioscar.com/forms or
by calling the Member Services Team at 1-855-OSCAR-55.
Enrollment
Overview
Members on Individual & Family Plans
An individual who resides in the plan service area, and is not entitled to or enrolled in Medicare, is
eligible for Oscar coverage. The subscriber’s spouse or domestic partner and all dependent
children (including those who qualify under a “Qualified Medical Child Support Order”) may also
be eligible to enroll with Oscar at the same time. Qualified individuals are only permitted to enroll
in a Qualified Health Plan (QHP), or as an enrollee to change QHPs, during the annual open
enrollment period or a special enrollment period for which the individual has experienced a
qualifying event.
Members on Employer-Sponsored Small Group Plans
Individuals who are actively employed by the group policyholder are eligible for coverage. The
subscriber’s spouse or domestic partner and all dependent children (including those who qualify
under a “Qualified Medical Child Support Order”) may also be eligible to enroll with Oscar at the
same time. Employees and their eligible dependents are only permitted to enroll in an Oscar small
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group policy during the group’s initial enrollment period, during the annual enrollment period or
during a special enrollment period for which they have experienced a qualifying event.
Open Enrollment Period
The annual open enrollment period for individual health insurance plans is designated by the
Department of Health and Human Services. Individuals may enroll in a plan, switch from another
plan to Oscar or from Oscar to another plan and apply for subsidies within this period. This is the
only time period during which individuals may obtain an Oscar individual plan, both off and on
the health insurance marketplace, unless the individual has a qualifying life event and qualifies for
a special enrollment period.
Special Enrollment Period
A special enrollment period is a period during which a qualified individual (together with his or her
spouse and dependents, if applicable), experiences a qualifying life event or changes in eligibility,
outside of the open enrollment period. Individuals may enroll in an Oscar plan, switch from
another carrier’s plan to Oscar, or switch from Oscar to another carrier’s plan.
Grace Periods
Oscar's grace period policy is as follows, unless otherwise specified by applicable state or federal
law:
Formembersnotreceivingsubsidies(advancepremiumtaxcredit(APTC)):Oscar
provides a grace period of 31 days to members who are not receiving APTC and who
have previously paid at least one full month's premium during the benefit year. During the
grace period, the policy will remain active. If any premium is not paid by the end of the
grace period, coverage will be terminated as of the end of the period for which premium
has been paid. Any payments made to a provider on behalf of a member who ultimately
loses coverage due to non-payment of premiums will be refunded to Oscar by the
provider within forty-five (45) days of receipt of written request by Oscar. Any
amounts not paid within forty-five (45) days of receipt of notice from Oscar may be offset
by Oscar from amounts otherwise owed to the provider without any further action
required. Oscar will deny claims that are received and not processed with dates of service
beginning on the day following the last day the premium was paid after Oscar has
confirmed that the grace period expired without premiums being paid in full.
For members receiving APTC: Oscar provides a grace period of three months to
members receiving APTC who have previously paid at least one full month's premium
during the benefit year. During the grace period, Oscar will:
● Pay all appropriate claims for services rendered to the member during the first
month of the grace period and pend and/or deny claims for services rendered to
the enrollee in the second and third months of the grace period; and,
● Notify providers at the time the provider confirms the member's eligibility of the
possibility for denied claims when a member is in the second and third months of
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the grace period; and,
● Request a refund of any payments made in the second or third months of the
grace period if the member is ultimately terminated.
If a member receiving APTC exhausts the three-month grace period without paying
all outstanding premiums, Oscar will terminate the member's coverage on the last day of
the first month of the three-month grace period and deny claims incurred during the
second and third months of the grace period. Any payments made to providers on
behalf of members who ultimately lose coverage due to non-payment of premium with
dates of service beginning after the first month of the three-month grace period will be
refunded to Oscar by the provider within forty five (45) days of receipt of written request by
Oscar. Any amounts not paid within forty-five (45) days of receipt of notice from Oscar
may be offset by Oscar from amounts otherwise owed to the provider without any further
action required. Oscar will deny claims that are received and not processed with dates of
service beginning after the last day of the first month of the three-month grace period after
Oscar has confirmed that the grace period has expired without premiums being paid in full.
If the member pays in full during the three-month grace period, claims will be processed
as usual.
Eligibility
Verifying Eligibility
While providers are responsible for verifying member coverage and benefits prior to rendering any
non-emergency services or treatments, we've made it easy for you to identify our members.
Since we offer different plans and you may not participate in every plan, it is important that you
verify the member is eligible for the specific plan(s) in which you participate. If a member is eligible
for an Oscar plan in which you do not participate, you should refer them to a provider that
participates in that plan or tell the member to call Oscar member Services so that we can arrange
for the member to see a provider who participates in their plan.
If the member is enrolled in non-Oscar coverage on the date of admission, that other program or
health plan shall be responsible for payment of all covered inpatient facility and professional
services provided from the date of admission until the date the member is no longer confined to
an acute care hospital, regardless of what program or health plan the member is enrolled in at
discharge.
Member ID Cards
All Oscar members receive and should present to you a member Identification Card (ID). The
following information can be found on the most common Oscar ID Cards:
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1. Member first and last name
2. Name of the member’s plan
3. Member ID #
4. Member’s primary care provider (where applicable)
5. Contact information for Member Services
6. Cost to the member, before and after, deductibles
7. Member Rx Information
8. Provider and pharmacist services contact information
9. Mental health contact information
10. Pediatric vision and dental providers
11. Claims Information (where to send claims based on services provided)
12. Space reserved for vendor and partner logos
Please note that there may be differences between Oscar member IDs based on market and / or
the Oscar member's individual plan.
Verifying Benefits
To verify benefits, log in to Oscar’s Provider Portal ( www.hioscar.com/providers). Alternatively, you
may call Oscar Provider Services at 1-855-OSCAR-55 and request assistance with benefit
verification.
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Newborn Eligibility
Depending on the state, newborn children may be automatically covered for the first 31 days of
life. A child whose adoptive or parental placement has occurred within thirty-one days of birth, will
also be considered a newborn child.
Plan Design Details
Overview
Oscar offers a variety of plan designs and benefits. Please reference State Specific Supplement(s)
for details on state-specific plan designs.
Diabetes Care Plan
Beginning in 2022, Oscar is offering a unique benefit plan - Silver Simple - For Diabetes (Diabetes
Care Plan). This plan is available for individuals and families in 14 markets: AR, AZ, FL, GA, IA, IL,
KS, MO, NC, NE, OH, OK, PA TX. Oscar members enrolled in this plan will have an ID Card
unique to this product.
The Diabetes Care Plan offers enrollees with more ways to save on diabetic care including $0
cost-share on eligible services and affordable options for insulin and diabetic supplies. Enrollees
in this plan also have access to Livongo and may receive wellness incentives for their
participation. A diabetic diagnosis (type 1 or type 2) is required to obtain some plan benefits and
associated incentives. However, a diabetic diagnosis is not required for enrollment into the plan.
Claims and Payment
Overview
This section outlines Oscar’s claims policies and processes.
In-network providers will be reimbursed according to the rates established in their Provider
Agreements. In the event that multiple contracted rates apply to a claim (including
scenarios in which a provider is both directly contracted with Oscar and part of a leased
network or contracted provider organization), or that contracted rates exceed billed
charges, Oscar, in its sole discretion, may pay the claim at billed charges or in
accordance with the agreement with the lesser reimbursement rate.
Claims Submission
Providers may submit claims electronically or by mail.
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Oscar highly recommends that providers submit claims electronically via Change Healthcare
using Oscar’s payor ID: OSCAR. If you are having any issues setting up the ability to submit
claims electronically, please contact your billing vendor to ensure they have Oscar’s payor ID in
their system.
For all claims submitted via mail, Oscar requires the CMS-1500 Form for professional services and
the UB-04 Form for facility services. These forms are available for download on the Forms section
of www.provider.hioscar.com/resources/.
● CMS-1500 Claim Form: Required for all provider services claims, including internal
medicine, gynecology and psychiatry. The International Classification of Diseases (ICD-10)
diagnosis codes and HCPCS/CPT procedure codes must be used. All field information is
required unless otherwise noted.
● UB-04 Claim Form: Required for all institutional services claims. All field information is
required unless otherwise noted.
For all claims submitted via mail, please send to the mailing address below:
Oscar Health, Inc.
P.O. Box 52146
Phoenix, AZ 85072-2146
If unlisted or miscellaneous codes are used, notes and/or a description of services rendered must
accompany the claim. Using unlisted or miscellaneous codes will delay claims payment and
should be avoided whenever possible. Claims received with unlisted or miscellaneous codes that
have no supporting documentation may result in a claim denial, and the member may not be held
liable for payment.
Please consult the “Our Delegated Vendors” section of the Provider Manual and/or the State
Specific Supplement(s) for electronic and paper claims submission guidance for behavioral
health and substance abuse, pediatric dental, pediatric vision, and prescription/specialty
pharmacy services. Please note that Oscar does not offer routine dental or vision coverage for
adults.
Timely Filing of Claims
Providers must claim benefits by sending Oscar properly completed claim forms itemizing the
services or supplies received and the charges within the timely filing deadline. Oscar will not be
liable for benefits if Oscar does not receive completed claim forms within this time period. Claim
forms must be used; canceled checks or receipts are not acceptable. Deadlines for timely filing of
claims are documented in the State Specific Supplements.
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Requests for Additional Information
During the claim’s adjudication process, Oscar may request additional information—such as
medical records, acquisition invoices, or itemized bills— from the provider in order to better
ascertain financial liability and whether the services on the claim should be reimbursed. Oscar will
make any requests for more information within timelines set by state regulations or the Provider’s
Agreement with Oscar.
Guidelines for Additional Information
The following content guidelines for medical records and itemized bills will ensure timely
processing of claims requiring additional information. All requested documents must be legible
and must present the information in a way that can be reasonably interpreted.
Medical Record Content
Complete medical records requested for the purpose of claim payment must include the content
outlined below only for the requested dates of service. The content is as follows but is not limited
to:
● Member demographics
● Biographical Information
● Consultation reports including specialist consultations
● History and physical examination
● Daily clinician notes
● Physician’s Orders
● Laboratory reports
● Vitals
● Medication list
● Diagnostic tests
● Imaging results, if applicable
● Preventative health records including immunizations
● Operative notes, if applicable
● Inpatient/ER discharge summary reports, if applicable
● Progress or office visit notes, if applicable
Itemized Bill Content
An itemized bill will appropriately reflect line items, supplies, and services billed under the
applicable revenue codes. A complete itemized bill must contain the following information:
● Member demographics
● Admit date / discharge date
● Revenue codes
● CPT and HCPCS codes, if applicable
● Date of service per item
● Description of service per item
● Quantities per item
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● Amount billed per item
● Total billed charges
Providers should refer to their respective Agreements for timelines when submitting requested
additional information for claims. Unless a different timeline is specified in the Agreement,
providers must submit the requested information to Oscar, along with the associated Explanation
of Payment (EOP) and / or a copy of the information request letter, within the timelines specified in
State Specific Supplement(s). If all requested documentation is not received within this timeframe,
Oscar will deny the claim. The member cannot be held financially responsible for claims denied
due to the provider’s failure to submit requested documentation. All requested documentation
should be sent to the addresses, and within the timeframes specified in the State Specific
Supplement(s).
Oscar will not be liable for interest or penalties when payment is denied or recouped as a result of
failure to submit required or requested documentation for claims.
If the requested documentation received from the provider is insufficient or incomplete, Oscar will
send additional requests to the provider detailing what information is still outstanding. All requests
(including subsequent requests made per incomplete documentation) must be fulfilled within the
timelines specified in State Specific Supplement(s). Oscar will not be liable for claim payment or
interest unless and until the documentation request has been properly satisfied, at which time the
applicable timeframe for processing the claim will commence.
Timely Processing of Claims
Oscar and its delegated provider organizations and hospitals are required to meet the claims
timeliness standards established by state law. Oscar will abide by the guidelines of the State level
Department of Insurance which are outlined in the State Specific Supplement(s).
Enrolling in ACH & ERA
Oscar offers ACH/EFT and ERA to both in-network and out-of-network providers. Please follow
the instructions below based on your network status:
In-network Providers: Please enroll via the Manage Payments section of the Oscar
Provider Portal (www.provider.hioscar.com). In-network providers must enroll in ACH
before enrolling in ERA. If you do not have an account with the Oscar Provider portal, you
can create one here: www.provider.hioscar.com/account/v2/new.
Out-of-network Providers: Required to enroll in ACH and ERA at the same time.
Enrollment Steps:
● Complete the Oscar ACH & ERA enrollment form here:
www.docs.google.com/forms/d/e/1FAIpQLScnVFnNJbwXzro0ln5WJKwXCuyp-vW
4BgXxTsw4TTJrl7KpIQ/viewform
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● Complete the Change Healthcare ERA Enrollment form here:
www.support.changehealthcare.com/customer-resources/enrollment-services/med
ical-hospital-era-enrollment-forms#sort=relevancy&numberOfResults=12
● Contact Oscar once you have received two small deposits into your bank account
(these deposits are part of a verification process conducted by the bank)
For questions, please refer to Oscar’s Provider Portal or call us at 1-855-OSCAR-55.
Incomplete Claims
Unless otherwise required by law or regulation, a complete claim:
● Includes detailed and descriptive medical and patient data
● Includes all the data elements of the UB-04 or CMS-1500 (or successor standard) forms
(including but not limited to member identification number, National Provider Identifier
(NPI), date(s) of service, and a complete and accurate breakdown of services)
● Does not involve coordination of benefits
● Has no defect or error (including any new procedures with no CPT codes, experimental
procedures, or other circumstances not contemplated at the time of execution of your
Agreement) that prevents timely adjudication.
Claims that are determined to be incomplete due to incorrect or missing required information (e.g.
invalid CPT codes) will be denied. Providers will need to re-submit these claims with the
appropriate information for the claims to be adjudicated.
Claim Denials
Oscar will send an Explanation of Benefits to members in situations where a denied claim could
lead to member financial responsibility. The Explanation of Benefits will include the reason for
denial as well as an explanation of appeal rights.
Claim Corrections and Late Charges
Providers who believe they have submitted an incorrect or incomplete claim may submit an
updated claim within the time frame specified in the State Specific Supplement(s) (the same timely
filing limit established in the “Timely Filing of Claims” section above). Providers must submit a
corrected claim when previously submitted claim information has changed (e.g. procedure codes,
diagnosis codes, dates of service, etc.). When a claim is submitted as a correction or
replacement, the entire claim must be submitted. Paper CMS 1500 corrected claim submissions
must use Frequency Code 7 under Item 22 (Resubmission Code) and the corresponding original
reference code field must list the original payor claim ID. Paper UB-04 corrected claims must be
submitted with Claim Frequency Type 7 as the third digit under Type of Bill (Form Locator 04).
Electronic corrected claims must be submitted with frequency code 7 in Element CLM05-3 (Claim
Frequency Type Code). Updated claim submissions that do not have these codes may be denied
as duplicate submissions.
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If it is determined that Oscar made a claim-processing error, Oscar will send the claim for
correction and no additional action is required by you. If it is determined that there was an
omission or incorrect information was submitted on the claim (e.g. missing field or missing
modifier), you will be asked to submit a corrected claim to the address on the participant’s Oscar
ID card. Include “Corrected Claim” on the re-submission. The claim will be re-evaluated with this
new information.
Claims for Emergency Services
Emergency services do not require prior authorization. However, post-stabilization services
require notification and may be subject to concurrent or retrospective review and medical
necessity determination.
Oscar abides by all state and federal regulations related to surprise billing.
Collection of Cost Share
Covered services provided to Oscar members may be subject to a deductible, a coinsurance
amount, and/or a copayment amount. In these cases, the member will be liable for reimbursing
the provider the relevant amount.
Oscar encourages providers to collect copayments upfront but to defer the collection of
coinsurance and deductible amounts until Oscar has adjudicated the claim and an Explanation of
Payment (EOP) or 835 electronic remittance notice has been received. If a provider prefers to
collect member cost share upfront, the provider is expected to collect the cost share as outlined
in the member’s Schedule of Benefits (found at www.hioscar.com/forms), never exceeding the full
negotiated rate for the services rendered.
Oscar encourages providers to check with the member whether the member expects other
medical or prescription spending to occur on that day. If the member anticipates further spending,
Oscar encourages the provider to account for those amounts in the upfront collection.
If a provider collects an upfront amount that exceeds the member’s cost share indicated in the
EOP, Oscar requires the provider to issue a refund to the member within 30 working days of
receipt of the EOP.
Copayment and coinsurance amounts for the most common services are indicated on a
member's ID card. Providers can also check a member's outstanding copayment amount,
coinsurance amount, or deductible by calling Oscar Provider Services at 1-855-OSCAR-55 or
logging onto www.provider.hioscar.com.
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Provider Inquiry
Providers who would like to make a claims inquiry may contact Oscar via phone, web, email, fax,
or letter sent to the address specified on the EOP. Inquiries leading to the submission of adjusted
claims or late submissions will be reviewed according to the timelines established in the claim
submission section.
Coordination of Benefits (COB)
The Coordination of Benefits (COB) applies when a person has health care coverage under more
than one plan. The order of benefit determination rules govern the order in which each plan will
pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must
pay benefits in accord with its policy terms without regard to the possibility that another plan may
cover some expenses. The plan that pays after the primary plan is the secondary plan. The
secondary plan may reduce the benefits it pays so that payments from all plans equal 100 percent
of the total allowable expense. To maximize efficient and accurate payment of your claims and to
avoid recoupment requests, you should assist Oscar and bill services to the responsible primary
plan first.
If COB information is not included with the electronic claim or a copy of the primary EOP is not
included with the paper claim, Oscar may not be able to pay the claim until the requested
information is received. For more information about requirements for complete claims, go to the
“Incomplete Claims” section of this Manual.
Oscar Payor ID: OSCAR is able to receive COB claims electronically; please contact your billing
vendor for information on how to submit these claims. For more information about electronic
claims, go to the “Claims Submission” section of this Manual.
When Oscar is not primary payor
When the Oscar plan is secondary, tertiary, or other non-primary payor, first submit the claim to
the primary plan. After receiving a payment or denial notice from the primary plan, submit the
claim to Oscar, along with a copy of the primary plan EOP. Paper copies are not required if you
submit HIPAA-compliant COB content electronically through an EDI claims submission.
In the event that Oscar pays the full contracted rate on a claim for which Oscar is not the primary
payor, a refund may be requested for the overpaid amount. This recoupment may be pursued by
Oscar or by a vendor on Oscar’s behalf. Oscar or its vendor may request a copy of the primary
insurer’s EOP to calculate Oscar’s responsibility as secondary payor. If the primary EOP is not
provided upon request, Oscar may recoup the entire claim as an overpayment.
Workers’ Compensation
All claims paid by Oscar are reviewed post-payment to identify any claims that may qualify for
workers’ compensation coverage. Part of this review process may include an Oscar vendor
contacting the patient for information about the case. If it is determined that we have made a
medical payment on a valid workers’ compensation case, we may require a refund. The vendor
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will provide information about that process. In this case, you should then resubmit the claim to the
workers’ compensation carrier responsible for payment and submit the full refund to Oscar’s
vendor or Oscar directly.
The coverage provided under the member’s policy is not in lieu of and does not affect any
requirements for coverage by workers’ compensation insurance or law. Workers' compensation
claims that are not a benefit under the member’s policy are not payable by Oscar.
Reimbursement Requirements and Policies
Balance Billing Reimbursement
Except for cost share (copayments, coinsurance, deductibles), providers must not invoice or
balance bill Oscar members for the difference between the provider’s billed charges and the
reimbursement paid by Oscar. Additionally, if providers do not comply with rules laid out in their
Agreements, in this Manual, or by state regulators (e.g. timely filing, surprise bills,
pre-authorization checks, etc.), providers cannot hold members liable for payment.
Interim Billing
Oscar does not accept interim claims for inpatient services. Claims may only be billed upon
patient discharge.
Interest Payments
Interest on Late Payments
Oscar and its delegated provider organizations will pay interest at a rate applicable as per the
State Specific Supplement(s) unless otherwise specified in the provider contract, of the payment
issued to the provider (excluding copayments, coinsurance amounts, and deductibles) on claims
for which the original payment is not mailed before Oscar’s state-mandated timely payment
deadline.
Interest on Underpayments
If Oscar does not pay a complete claim correctly and adjusts the claim or pays outside the
state-mandated time frame, Oscar will pay interest and / or penalties in accordance with
requirements in the State Specific Supplement(s).
Good Faith Payments
If Oscar, in its sole discretion, determines that it has denied or reimbursed a claim correctly but
agrees to overturn the denial or issue additional payment in the interest of the member, these
“Good Faith Payments” will not be eligible for any interest or penalties related to late payment.
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Reimbursement Policies
Oscar reimburses in-network providers according to the policies listed in the policies section of
the Provider Portal. Oscar may modify its reimbursement policies at any time by publishing new
versions to the Portal and providing advance notice to providers of expected changes in
accordance with state law, if applicable. Oscar’s Reimbursement Policies can be found in the
Policies section of the Provider Portal: www.provider.hioscar.com/resources/.
Oscar abides by all state and federal regulations related to surprise billing.
Claims Overpayment
Should Oscar determine that it has overpaid a claim, Oscar will submit a written refund request to
the provider. This request will include the patient’s name, date(s) of service, amount of
overpayment, and an explanation of how Oscar determined that an overpayment had been made.
Oscar must make any refund requests within the time frame specified in the State Specific
Supplement(s). However, such time limit shall not apply where state law explicitly permits,
including but not limited to, certain instances relating to suspected or actual fraud, waste, or
abuse.
Upon receiving this request, the provider must issue the refund or submit a clear, written
explanation of why the refund request is being contested within 30 calendar days of the date the
notice of overpayment was received. If the provider contests the refund request, the provider
must identify the portion of the overpayment that is contested and the specific reasons for
contesting the overpayment.
Providers should send refund checks or written notices contesting refund requests to the mailing
address listed below:
Oscar Health, Inc.
ATTN: Provider Refunds
615 S. River Drive
Tempe, AZ 85281
Should the provider fail to issue the refund or notify Oscar of a contested overpayment within the
defined timeframe, the amount of the overpayment may be deducted from future claims payments
until Oscar has been fully reimbursed. A written explanation will accompany all deductions made
from future claims payments.
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Utilization Management
Overview
Oscar’s Utilization Management (UM) Program promotes the delivery of high-quality, medically
necessary, cost efficient care for members. The UM Plan outlines policies and procedures by
which Oscar determines medical necessity, access, availability, appropriateness, and efficiency
for clinical services and procedures based on a member’s health benefits.
Oscar’s Utilization Review (UR) activities include pre-service (precertification or prior
authorization), concurrent, and post-service (retrospective) reviews. It is important to note that
neither prior authorization nor notification is required for Emergent or Urgent Care; however,
post-emergent inpatient admissions do require authorization. Oscar does not require its members
to select primary care physicians (PCP) for their plans and thus does not require review for
referral to specialists or any other provider in the Oscar network.
Oscar maintains a UR process to:
● Gather pertinent clinical information for each case
● Apply case specific criteria based on an individual’s characteristics (e.g. age,
comorbidities, family health history, and other factors)
● Notify providers and members of the utilization decision according to the timeframes
required by NCQA or state and/or federal regulations
Authorization is provided when a requested service is a covered benefit, deemed medically
necessary, and provided in the most efficient and cost-effective manner without compromising
quality of care. Benefits are provided only for services that are medically necessary. When a
setting or place of service is part of a review, services that can be safely provided in a lower-cost
setting will not be deemed medically necessary if they are performed in a higher-cost setting. For
example, Oscar will not approve an inpatient admission for surgery if the surgery could have been
performed on an outpatient basis, or an infusion or injection of a specialty drug provided in the
outpatient department of a hospital if the drug can be provided in a physician’s office or the
home setting.
In some cases, Oscar uses vendors with expertise in particular clinical functions to oversee
utilization and coverage determinations. For these cases, the UM Program includes the
management and oversight of these vendors as detailed in the “Delegation and Oversight”
section of this Manual.
Authorization Request Requirements
In general, the following information is required to submit an authorization request:
● Member information including first and last name, Oscar ID, and date of birth
● Referring/ordering provider name information (NPI, TIN, and contact information)
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● Attending/billing provider name information (NPI, TIN, and contact information)
● Facility, if applicable, (NPI, TIN, and contact information)
● Requestor’s contact information (phone and fax number)
● The healthcare service being requested including procedure codes, requested number
ofunits or visits, and length of treatment(s).
o For pharmacy reviews: Drug name, strength, and dosing
● Diagnostic codes
● Clinical information relevant to the authorization request which may include clinical notes
including consultation notes, labs, radiology, and other health pertinent information
To confirm authorization requirements for a specific code or service or to submit an authorization
request, use Oscar’s Provider Portal at www.provider.hioscar.com or call 1-855-OSCAR-55.
Providers can use this same phone number to request authorizations and check the status of an
existing authorization. For services where Oscar delegates utilization review, you will be
transferred to or instructed to contact the appropriate vendor. You may also request authorization
by faxing the Authorization Request Form, located on www.hioscar.com/forms, to the number
provided on the form.
If we do not receive the information necessary to intake your authorization, you will be notifiedof
the missing elements and asked to resubmit your request.If any of the clinical information
necessary to render a UR determination is missing, Oscar will reach out for the missing
information which may delay the UM process. To avoid processing delays, Oscar encourages
initial submission of complete requests including the clinical information necessary for review.
Authorization Request Communication
All determinations or requests for more information in order to make an initial UR determination
are made in a timely fashion appropriate for the member’s specific condition, not to exceed the
timeframes required by NCQA or state and/or federal regulations. Decisions are communicated
verbally and/or in writing to members and providers as required by regulations.
Oscar will not reverse a UM approval where the provider relied upon written or oral authorization
of Oscar (or its agents) prior to providing the service to the covered person, except in cases where
there is material misrepresentation or suspected fraud.
Same or Similar Specialty Review
In some states, providers may request that a prior authorization request be reviewed by a
physician in the same specialty as theirs, or by a physician in another appropriate specialty, or by
a pharmacologist. When relevant, this is indicated in the State Specific Supplement(s).
Clinical Criteria
The UM Program, under the direction of the Chief Medical Officer (CMO) and the designated
30
Medical Director, and with input and review by a quality subcommittee, develops and approves
written clinical criteria and protocols for the determination of medical necessity and
appropriateness of healthcare procedures and services. Clinical criteria are:
● Based on nationally recognized standards
● Developed in accordance with the current standards of national accreditation entities
● Developed to ensure quality of care and access to needed healthcare services
● Evidence-based
● Evaluated and updated at least annually
Current criteria used by Oscar include:
● Oscar’s Clinical Guidelines
● CVS Criteria
● Hayes, Inc.
● Up-to-Date
● Authoritative peer-reviewed textbooks and journals
● National society guidelines
● Agency for Healthcare Research and Quality
● NIH Consensus Statements
● MCG*
*Note: MCG criteria are national, standardized benchmark criteria developed with input and involvement from physicians and other
licensed healthcare providers and based upon generally accepted medical standards. Oscar uses the most recently released version
of MCG criteria. MCG criteria are reviewed and updated annually.
As listed above, Oscar may cite current clinical evidence from established and reliable sources.
Oscar also evaluates the adoption of new medical technologies for medical/surgical procedures,
behavioral health, pharmaceuticals, and medical devices to be used in the utilization decision
process.
For certain services, Oscar has partnered with outside vendors for UR activities. These vendors
have adopted their own specialty criteria, which are reviewed and approved annually. These
vendors are overseen by Oscar's UM staff as explained in the “Delegation and Oversight” section
of this Manual. See the “Delegation and Oversight” section of the State Specific Supplement(s)
for UM vendors and the associated service categories they manage.
Oscar also considers the local network and delivery system available to members with specific
needs, e.g. for services rendered by skilled nursing facilities, subacute facilities, and home health
agencies. Oscar reviews an individual member’s unique situation and provides specific guidance
tailored to the member and any special circumstance.
The UM Program maintains a list of medical procedures and services that require utilization
review, which is shared on the Oscar website. This list is reviewed annually by the Chief Medical
Officer and the designated Medical Director as well as by the Utilization Management
Subcommittee.
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The following factors are considered when building this list:
● Risk of fraud, waste, and abuse (including overuse and misuse)
● Availability of alternatives that may be a more appropriate first course of treatment
● Whether coverage of a given benefit is contingent on medical necessity
Oscar’sClinicalCriteriaaremadeavailabletoenrolleesandprovidersatwww.hioscar.com/clinica
l-guidelines.A hard copy of Oscar's Clinical Criteria is also available upon request by calling
1-855-OSCAR-55. Additional clinical criteria (e.g. MCG) used by Oscar are made available to
members and providers upon request. In the case of an adverse determination, the clinical
criteria relevant to the review are summarized in a letter to the provider and member.
Program Staff
Oscar’s Chief Medical Officer and designated Medical Director are ultimately responsible for the
UM Program. With a full, unrestricted license to practice medicine issued by the respective state,
the designated Medical Director maintains authority over all UM activities, including
implementation, supervision, oversight, and evaluation of the Program. This includes ultimate
oversight and accountability for all adverse determinations relating to members in an Oscar plan,
whether made by an Oscar employee or delegated utilization review agent.
Table 1. Oscar Utilization Management staff
Staff
Authority to issue
Adverse Determination?
Licensed
Physicians
Yes
Licensed
Pharmacists
See State Specific
Supplement(s)
Licensed Nurses
No
Clinical
Operations Staff
No
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Board-Certified
Physician
Consultants
No
Non-licensed
Staff -
Processors
No
Any adverse determinations (medical necessity denials) are reviewed and ultimately made by a
physician or psychologist with an active license issued by a state licensing agency in the United
States.
Oscar promotes consistent application of review criteria across its UM staff by conducting regular
internal audits of determinations made by all clinical UM staff as well as annual inter-rater
reliability testing (IRR). In IRR testing, clinicians are given the same clinical scenario and asked to
demonstrate their decision making so that differences in determinations can be used as the basis
for remediation and training.
Oscar staff are available at least eight (8) hours per day during normal business hours, and
outside normal business hours for urgent requests. Staff are identified by name, title, and
organization name when initiating or returning calls regarding UM issues. TDD/TTY services and
language assistance are available (via the main Oscar phone number: 1-855-OSCAR-55) for
callers as well.
Oscar’s UM Program affirms the following:
● UM decision-making is based only on appropriateness of care and service and existence
of coverage
● Oscar does not reward practitioners or other individuals for issuing denials of coverage
● Financial incentives for UM decision-makers do not encourage decisions that result in
under utilization
Services Requiring Authorization
The list of services subject to pre-authorization can be accessed online:
www.hioscar.com/prior-authorization. Review requirements (prior authorization, concurrent,
and/or retrospective review) for Behavioral Health & Substance Abuse are subject to the policies
33
and procedures of Optum. It is important to submit any elective or pre-service requests in
advance to ensure everything is in place for your patients to get the right care. If prior
authorization is not obtained, they are subject to post-service (retrospective) review. Some
services that may be a part of an ongoing course of treatment may also be subject to concurrent
review.
Please note that the list of services within each category might not be exhaustive and inclusion of
a benefit in the Oscar Authorization List is not a guarantee of coverage. Coverage of these
benefits may vary by plan, and the Authorization List is subject to change. To confirm
requirements for a specific code or service, request authorization, or check the status of an
existing authorization, reference the authorization aool at www.provider.hioscar.com or call
1-855-OSCAR-55. Authorization requests may also be submitted by faxing the Authorization
Request Form found on www.hioscar.com/forms to the number provided on that form.
Review for certain services is delegated to eviCore healthcare. For access to the clinical criteria
used by eviCore and authorization request forms, please visit:
www.evicore.com/healthplan/Oscar. For any other services not indicated in these resources, you
can call 1-855-OSCAR-55 or follow the instructions on the Oscar Authorization Request Form
available at www.hioscar.com/forms.
Failure to Preauthorize
If any treatment or service described above is not pre-authorized and it is determined that the
treatment, service, or extension was not medically necessary or experimental / investigational,
benefits may be reduced or denied.
Emergency, Urgent, and Ambulance Services
No prior authorization is required for emergent or urgent services, including emergency
ambulance. Members who reasonably believe they have an emergent medical condition that
requires an emergency response are encouraged to appropriately use the 911 emergency
response system where available. Emergency ambulance services are covered from the site of
the medical emergency to the nearest appropriate facility or between facilities when a higher level
of care is required to stabilize and treat an emergency medical condition.
Oscar participating hospitals are responsible for notifying Oscar of an emergent/urgent inpatient
admission within 48 hours, unless otherwise specified in your Agreement. Non-participating
hospitals are required to notify Oscar prior to any emergent/urgent inpatient admission when
further care or treatment is needed following stabilization of an emergent/urgent condition. Failure
to comply with Oscar’s notification requirements will result in an administrative denial of the claim
payment. Members cannot be held liable for claims denied for failure to notify. Notification may
be communicated by fax (see the Authorization Request Form at www.hioscar.com/forms for fax
number) or phone (1-855-OSCAR-55) to speak with Oscar’s Clinical Review Team.
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Oscar abides by all state and federal regulations related to surprise billing.
Post-Stabilization
If applicable, post-stabilization procedures and/or requirements are listed in the State Specific
Supplement(s).
Second Medical Opinion Coverage
Second Cancer Opinion
We cover a second medical opinion by an appropriate specialist, including, but not limited to, a
specialist affiliated with a specialty care center, in the event of a positive or negative diagnosis of
cancer or a recurrence of cancer or a recommendation of a course of treatment for cancer.
Second Surgical Opinion
We cover a second surgical opinion by a qualified physician on the need for surgery.
Required Second Surgical Opinion
We may require a second opinion before we preauthorize a surgical procedure. There is no cost to
[the member] when we request a second opinion.
● The second opinion must be given by a board-certified specialist who personally examines
the member.
● If the first and second opinions do not agree, the member may obtain a third opinion.
● The second and third opinion consultants may not perform the surgery on the member.
Second opinion services must be obtained by an in-network provider. In cases where there is not
an in-network provider with the appropriate specialization to conduct the second opinion, we may
authorize the member to obtain a second opinion from an out-of-network provider. Please refer to
the “Authorizing an Out-Of-Network Provider” section of this Manual for more detail.
Experimental and Investigational Treatments
Oscar reserves the right to deny benefits as experimental, investigational, or unproven for any
service, treatment, therapy, procedure, device, or drug that is utilized in a manner contrary to
standard medical practice or that has not been demonstrated through medical research to have
a beneficial impact on health outcomes. If coverage is denied, an appeal may be submitted,
including any pertinent medical records and/or supporting medical evidence.
If applicable, any exceptions to Oscar’s decision-making on experimental and investigational
treatments can be found in the State Specific Supplement(s).
Delegation and Oversight
Oscar contracts with vendors to conduct UR for certain service categories. In these cases, Oscar
35
UM staff is responsible for oversight of the delegated vendor for both clinical and operational
purposes. The vendors Oscar utilizes nationally for UR are listed below. Additional vendors and
corresponding services are listed in the State Specific Supplement(s).
Delegate
Service Categories Delegated for UR
Optum
Behavioral health
LIBERTY Dental
Pediatric dental
Monitoring and Reporting of Utilization Management
Oscar retains documented UM policies and procedures as specified within the UM Plan and as
required by federal and state regulation. You may contact Oscar Provider Services
(1-855-OSCAR-55) with any questions about the UM Plan and related documentation, including
but not limited to:
● UM Plan, policies, and procedures, including clinical criteria and guidelines
● Utilization records including prior authorization approvals and denial letters
● Evidence of appropriate licensure, including of physician and other clinical reviewers
responsible for conducting utilization reviews
Oscar has utilization and claims management systems to identify, track, and monitor care
provided to members and to ensure its appropriateness. Oscar does not reward practitioners,
providers, or employees who perform utilization reviews for issuing denials of coverage or for
encouraging underutilization. Utilization review decisions are based on medical necessity and
benefit eligibility.
Peer-to-Peer Process
In the case of an Initial Adverse Determination, the provider of record is notified in the denial
notification of the opportunity to discuss a medical necessity denial with an Oscar UM physician.
If a request to schedule a peer-to-peer is received, scheduling and decisions will occur in a timely
fashion appropriate for the member’s specific condition, not to exceed timeframes required by
applicable state regulations. The Oscar physician will make two attempts to contact the provider
of record during the scheduled time. If the provider is unreachable, the Oscar physician will
supply their name, position, and contact information for Oscar Clinical Review to reschedule the
peer-to-peer. If applicable, pre-denial peer to peer procedures and/or requirements are listed in
the State Specific Supplement(s).
Audits
Claims Payment Audits
Oscar has the right to access confidential medical and billing records for the purpose of claims
36
payment, assessing quality of care (including medical evaluations and audits), and performing
utilization management functions.
Oscar conducts claims audits to ensure that billing is in accordance with Current Procedural
Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and International
Classification of Disease (ICD) guidelines, Oscar’s Reimbursement Policies, benefit policies,
medical policies (including authorization requirements), and provider contract terms.
At any time, Oscar or its contracted reviewers may request on-site, electronic or hard copy
medical records, utilization review sheets and/or itemized bills related to claims for the purposes
of conducting audits and reviews to determine medical necessity, diagnosis and other coding and
documentation of services rendered.
Claim audits may be performed on a pre-payment or post-payment basis, subject to the terms of
the Provider Agreement. Claim audits involving review of claims data, claims payments, and
medical records, and are performed on areas including, but not limited to:
● Billing with incorrect coding — CPT, HCPCS, ICD-10, modifiers, bundling/unbundling
services
● DRG validation
● Duplicate billing / services
● Prior authorizations not received/denied
● Historical claims review
● Coordination of Benefits (COB)
● Insurance liability and recovery
● Potential fraud, waste or abuse
Post-payment reviews may involve a sampling and extrapolation methodology, where applicable,
and may involve any amount of claims with no specified minimum amount involved or potential
recovery probability. The estimated error rate may be projected across all claims to determine
overpayment. Providers must supply all requested documentation including, but not limited to,
medical records or itemized bills. Failure to do so may result in denial of the entire sample and
apply to all claims within the review.
If an internal or contracted reviewer identifies an overpayment for any reviewed claims, Oscar will
make appropriate adjustments to the payments. If the reviewer is unable to review the records,
Oscar will make adjustments to payments based upon the information available to us at that time.
Any denials will be subject to the provider dispute or appeal rights process, depending on the
denial reason, specified herein and in the terms of the provider’s contract with Oscar.
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Credentialing
Overview
The Oscar network credentialing process is designed to provide initial and ongoing assessment of
the provider’s ability to render specific patient care and treatment within limits defined by
licensure, certification and/or accreditation. Oscar performs or provides oversight for all aspects
of the credentialing process, including primary source verification of provider information and
identification of potentially problematic providers.
All providers that meet requirements are referred to the Medical Director for review and final
approval. The Medical Director has the authority to refer any providers for further review to the
Credentialing and Peer Review Committee for final approval. If a reportable quality issue or trend
is identified, the Credentialing and Peer Review Committee takes appropriate action in
accordance with Oscar’s policies and procedures. Oscar providers have the right to formal fair
hearing and appeal if Oscar decides to alter the conditions of a practitioner’s participation based
on quality and/or service issues. Oscar complies with applicable state and federal requirements
and NCQA standards in credentialing and recredentialing its providers.
Practitioner Rights
All practitioners have the right to:
● Review the information Oscar obtains from outside sources (e.g. malpractice insurance
carriers, state licensing boards) to support their credentialing applications
● Correct erroneous information from outside sources within 30 days of identification
● Check the status of their credentialing or recredentialing application here:
www.provider.hioscar.com/provider-credentialing-status
If the Peer Review and Credentialing Committee makes a professional competence, conduct,
business, or administrative decision with regard to a practitioner’s participation status and the
Peer Review and Credentialing Committee offers such participating practitioner an opportunity to
appeal the recommendation, the Peer Review and Credentialing Committee will provide the
participating practitioner notice of the Peer Review and Credentialing Committee’s
recommendation, that:
● States the specific criteria, facts and circumstances that the Peer Review and
Credentialing Committee considered in making its recommendation
● Specifiestheproposedeffectivedateofitsrecommendation
● Summarizes the basis for the Peer Review and Credentialing Committee’s
recommendation
● Describestheparticipatingpractitioners
righttorequestahearingormeetingtoappealtherecommendation
● Setsforththetimelimitwithinwhichtorequestsuchahearing/meeting
38
● Generally, describes the appeal process and summarizes the participating practitioner’s
rights during the hearing / meeting
These rights to appeal apply exclusively to participating practitioner and organizational providers.
An applicant who does not have a Participation Agreement in place with Oscar at the time of
application has no appeal rights under this plan.
Practitioner Obligations
A Participating Practitioner has the obligation to continually update their CAQH application with
the most current information available with respect to all information and to notify Oscar
immediately upon the occurrence of those events. Failure to update the CAQH application or to
provide such notification to Oscar will constitute grounds for denial of the recredentialing
application and termination of Participating Practitioner’s participation status.
Credentialing Delegation and Oversight
Oscar may delegate credentialing activities to contracted provider organizations that have
administrative capacity to provide such services and meet delegation requirements as
demonstrated in a pre-delegation review. See State Specific Supplement(s) for additional
information regarding delegated entities.
Oscar performs, and requires delegated entities to perform, ongoing internal audits to ensure the
credentialing status of its providers remains current at all times. Audits include validation of
licensure, malpractice, DEA, OIG and other sanctions, and current status of applicable
certification and / or accreditation.
Non-Discrimination Policy
Oscar conducts monitoring, at least annually, to ensure that discriminatory decisions are not
made. Information submitted to the Credentialing Committee for approval, denial, or termination
does not designate a provider’s race, ethnic / national identity, gender, age, sexual orientation,
types of procedures performed, or payor sources.
Re-credentialing Process for Practitioners
Re-credentialing of providers occurs every three (3) years or more often if required by state law.
Information from Quality Management (QM), Utilization Management (UM), member Services, and
Appeals & Grievances is considered at the time of recredentialing. Provider status and
performance is continuously monitored between recredentialing cycles by Oscar or its delegated
entity. Ongoing monitoring of reports by regulatory agencies of sanctions, limitations on licensure,
and complaints are also performed between re-credentialing cycles.
39
Grievances and Appeals
Grievances
Oscar has a process for timely hearing and resolution of member grievances in accordance with
regulatory guidelines. The Senior Manager, Grievances and Appeals has primary responsibility for
Oscar’s grievance system and processing of grievances is not delegated to any other entity.
Oscar performs ongoing review and analysis of grievances in order to track and trend issues.
Analyses are reviewed by the Quality Management Committee and the Quality Improvement
Committee, and recommendations are made to improve plan policies and procedures.
Oscar provides assistance as needed to members filing grievances and maintains a toll-free
number for the filing of grievances. Grievance forms and a description of the grievance procedure
are made available at the Oscar headquarters, and on the Oscar website
(www.hioscar.com/forms).
Members may submit grievances via mail, fax, or email during the time frames defined in the
State Specific Supplement(s) using Oscar’s Grievance Form or by calling Member Services. A
written record is made for each grievance received by Oscar including the date received, the plan
representative recording the grievance, a summary or other document describing the grievance,
and its disposition. Please see below for methods of submission:
Mail:
Oscar Health, Inc.
P.O. Box 52146
Phoenix, AZ 85072-2146
Phone:
1-855-OSCAR-55
Email:
help@hioscar.com
Fax:
1-888-977-2062
Oscar’s grievance system addresses the linguistic and cultural needs of its member population
as well as the needs of members with disabilities. Oscar ensures there is no discrimination
against an enrollee or subscriber (including cancellation of the contract) on the grounds that the
complainant filed a grievance. Grievances will be addressed and resolved according to state
regulations.
Appeals
In cases where an authorization request is denied, the enrollee or the enrollee’s authorized
40
representative will have an opportunity to appeal the decision. The appeal will be handled
through a structured appeal process and a licensed physician not involved in the initial coverage
decision will review the appeal. Upon resolution of every internal appeal, a resolution letter is sent
to the member, which, in the case of an adverse determination, will include information regarding
any additional appeal rights the member might have and instructions on how to dispute the
determination. A copy of this letter will also be faxed to the provider and the member’s authorized
representative, if applicable.
An appeal of a denied utilization review (UR) decision, in which the services were determined to
not be medically necessary, should be filed within 180 days of the receipt of the denial (adverse
determination). In order to request an appeal, please specify that you are seeking to file an appeal
of a denied UR decision with the Clinical Review team, whether you submit your request via
telephone, or in writing. An Oscar Grievance and Appeal Form is available at
www.hioscar.com/forms, which the member may submit along with additional clinical
information, to initiate an appeal request.
Members or their authorized representatives may request an independent medical review of
disputed healthcare services if they believe that healthcare services have been improperly
denied, modified, or delayed by Oscar or one of its contracting practitioners.
Access to Care
Overview
Oscar is dedicated to providing access to high-quality providers and strives to ensure strong
network coverage for all Oscar members’ needs. Oscar will work with members and providers to
ensure members have access to appropriate, timely, and continued care. Providers may freely
communicate with patients about all treatment options, regardless of benefit coverage limitations.
Under benefit plans subject to this Manual, a member does not have to select a Primary Care
Practitioner (PCP) but is encouraged to do so. The PCP is available to supervise and coordinate
the member’s health care in Oscar’s network, and Oscar may assign each member to a PCP at
our discretion.
● Members on EPO and non-gated HMO plans (listed in the “Our Products Referenced in
this Manual” section) have full access to the Oscar network and do not have
out-of-network benefits except in emergencies (or if there are no in-network options).
EPO members do not need a referral to see a specialist.
● Members on PPO plans (listed in the “Our Products Referenced in this Manual” section)
have full access to the Oscar network and can access doctors, hospitals, and providers
outside of the network for an additional cost. PPO members do not need a referral to see
a specialist. Additional information on PPO benefits is available in applicable State
41
Specific Supplement(s).
Members can search for in-network providers and facilities by state on the Oscar website
(www.hioscar.com/care-options).
Availability Standards
Oscar expects to offer access for scheduling appointments with an in-network practitioner, mental
health professional, and specialist for medical/surgical services, per any state law and NCQA
guidelines. Oscar has adopted quantifiable and measurable appointment availability standards
consistent with state regulations and NCQA guidelines, including timeliness of appointments for
preventive care, routine primary care, specialty care, urgent care, emergency care, after hours
care, and waiting time in the provider office. Oscar’s appointment availability standards are
outlined in the State Specific Supplement(s).
Referrals
Benefit plans subject to this Manual are “open referral” plans. Members do not need a referral
from a PCP to obtain treatment for covered benefits before receiving specialist care from an
in-network specialist.
Authorizing an Out-of-Network Provider
If it is determined that Oscar does not have an in-network provider with the appropriate training
and experience needed to treat a member’s condition, Oscar will approve an out-of-network
authorization. Requests for out-of-network authorizations may be made by the member.
Please note: Approvals will not be made on the basis of convenience for either a member or a
provider, and Oscar may not approve the particular out-of-network provider requested. If Oscar
approves the authorization, all services performed by the out-of-network provider are subject to a
treatment plan approved by Oscar in consultation with the memberand the out-of-network
provider. All services rendered by the out-of-network provider will be paid as if they were
provided by an in-network provider, and members are responsible for any applicable in-network
cost-sharing. In the event that we do not approve an authorization, any services rendered by the
out-of-network provider will not be covered.
Continuity and Transition of Care
Oscar understands that when providers leave the network or are terminated from the plan
(Continuity of Care) or when members first join Oscar and their current provider(s) are not
in-network (Transition of Care), members may require coverage for a period of time to ensure
continuity or transition of treatment. As such, qualifying members may be able to continue
ongoing treatment for covered services. Qualification requirements are documented in Oscar’s
Continuity and Transition of Care Guidelines available at www.hioscar.com/forms. Oscar
42
encourages providers to submit these requests on behalf of our members. Members may also
submit these requests by contacting Member Services (1-855-OSCAR-55).
Please note: Continuity of Care or Transition of Care must be authorized prior to service. Formerly
in-network providers must agree to accept as payment the negotiated fee that was in effect just
prior to the termination. Additionally, the provider must agree to provide Oscar with necessary
medical information related to the member's care and adhere to Oscar's policies and procedures,
including those for assuring quality of care, obtaining preauthorization, authorization, and a
treatment plan approved by Oscar.
If a provider was terminated by Oscar due to fraud, imminent harm to patients, or final disciplinary
action by a state board or agency that impairs the provider’s ability to practice, continued
treatment with that provider is not available.
Fraud, Waste, and Abuse
Overview
Oscar takes Fraud, Waste and Abuse (FWA) very seriously. Oscar’s Special Investigations Unit
(SIU) is tasked with the detection, prevention, and investigation of FWA in the delivery of
healthcare services. Fraud, Waste, and Abuse are improper actions that result in inappropriate
and unnecessary spending:
● Fraud is distinguished from waste or abuse in that it is committed when one knowingly or
willfully makes a material misrepresentation or omission with the intent to defraud and
obtain a benefit
● Waste refers to overutilization, extravagant, careless or needless expenditure of
healthcare benefits or services often caused by disorganization or a misuse of resources
● Abuse describes practices that are inconsistent, or outside the bounds of generally
accepted practices in the industry, which result in unnecessary services and payment
Detection
Oscar uses a number of sources as well as proactive and reactive processes to detect FWA,
including but not limited to: Hotline reports, internal employee escalation, external industry
sources, pre-payment and post-payment claim review, claim edits, and data analysis. Any report,
regardless of source, may result in an investigation.
Prevention and Investigation
As part of its prevention and investigative efforts, Oscar’s SIU initiates investigations which may
include but are not limited to an audit of a provider's records. Pre-payment review may be
applied to the claims of a provider or member for whom there is a basis to suggest inappropriate
billing or services may be occurring. Post-payment review may be conducted when there is a
basis to suggest inappropriate billing or services relating to a provider or member after claims
43
have previously been processed and paid.
Pre and post-pay claims reviews entail a thorough review of submitted claims, and all available
information including requested information, to determine whether the data submitted on the
claim is accurately and appropriately supported. At times these reviews may be conducted at the
provider’s location. Information requested or reviewed onsite may include but is not limited to:
medical records, billing statements, evidence of member cost share collection, invoices,
administration records, test results, nursing notes, audit logs, provider’s orders, lab requisitions,
certificates of medical necessity as well as the medical record documentation that supports each
of these. Providers are responsible to ensure that their available documentation fully supports the
data, and medical necessity of the procedures, services, and supplies, submitted on the claim.
This includes, but is not limited to, compliance with the most stringent medical record
documentation standards that would apply, and Medicare’s Medical Record Documentation
standards in the absence of others, as well as compliance with national coding and billing
standards (e.g. CPT, HCPCS, ICD-10). These reviews may result in full denial of the claim or
specific claim lines if documentation is insufficient or does not substantiate data submitted.
Records that contain cloned documentation, conflicting information or other such irregularities
may be disallowed for reimbursement.
Additionally, a post-payment review may involve a sampling and extrapolation methodology,
where allowed, or may require the provider to cooperate in the performance of a self-audit to
resolve identified issues. Investigations may involve review of contemporaneous treatment
records as well as interviews with associated parties including members and providers.
Resolution
Based on the findings of an investigation, SIU may pursue corrective actions including but not
limited to: Provider placement or continuation on pre-payment review, provider education,
recovery of overpaid funds including claims offsets, repayment demands, legal action,
termination of contract, and reporting to state and federal regulators and / or law enforcement.
Reporting Fraud, Waste, and Abuse
If providers or provider organizations suspect potential FWA relating to Oscar in any form, they
must report it to Oscar immediately. To report, you can contact Oscar’s SIU in the following ways:
Online Portal:
www.hioscar.ethicspoint.com
Mail:
Oscar Health, Inc.
Special Investigations Unit
75 Varick Street, 5th Floor
New York, NY 10013
44
Email:
fraud@hioscar.com
Compliance Hotline:
1-844-392-7589
Please call the Compliance Hotline or submit through the Online Portal to report any general
compliance-related concerns (including reporting violations of law, regulations, policies, or
procedures) and questions about Oscar’s Compliance Program, or to seek advice about how to
handle compliance-related situations at work. All calls are treated confidentially, and callers can
remain anonymous if they so choose. Callers may be asked whether they are willing to identify
themselves so that an issue may be followed up with the caller after the call ends. Retaliation
against anyone who raises a concern is prohibited.
Quality and Population Health Management
Overview
Oscar is dedicated to providing best-in-class experience and quality of healthcare for our
members. Oscar’s vision is to reinvent how a health plan functions and its role in the lives of its
members, and our quality strategy and structure provides the foundation to achieve that vision.
We are focused on improving outcomes with innovative quality reporting, case management,
care coordination, population health programs, compliance activities, and programs to reduce
hospital admissions, improve patient safety, reduce medical errors, and minimize health
disparities.
All contracted provider organizations and their downstream providers are required to participate
in Oscar’s Quality Management and Quality Improvement (QI) Program. Participation includes
submission of encounter data, accurate and complete coding, and participation in review of
potential quality issues (PQI) and programs.
Quality and Performance Improvement
The purpose of the Quality Improvement (QI) Program is to improve health outcomes of members
by providing access to affordable, appropriate and timely healthcare and services, which is
routinely measured for compliance with established, evidence-based standards. This objective is
accomplished by accessing pertinent data, utilizing proven management and measurement
methodologies, and continuously evaluating and improving organizational service processes that
are either directly or indirectly related to the delivery of care.
The QI Program also provides a framework to evaluate the delivery of healthcare and services
provided to members. This framework is based upon the philosophy of continuous quality
45
improvement and includes the following considerations:
● Quality issue identification, oversight, corrective action plan assignment, and follow-up
● Oversight and monitoring of internal programs
● Tracking and trending identified plan and provider issues
● Utilization and medical management plans
● Management of Protected Health Information (PHI)
● Credentialing of practitioners and other providers
● Oversight of delegated entities for quality and medical management
● Population health
● Case management
● Clinical practice guidelines
● Member rights and responsibilities
The responsibility for developing and providing oversight of the QI Program rests with the QI
Committee of the Board. In order to foster communication with the practitioner and provider
networks, as appropriate, practitioners and designated behavioral healthcare practitioners are
invited to participate in the QI Program through planning, design, implementation or review. Any
network practitioner may be involved in the QI Program and / or attend and advise through
involvement in various clinical subcommittees. If you are interested in participating further in the
QI Program or attending a subcommittee meeting you can send an email to quality@hioscar.com.
Oscar does not delegate its QI Program. Oscar does delegate certain QI activities. If activities are
delegated to an approved entity, Oscar will:
● Establish a written delegation agreement outlining the scope of that delegate's
responsibilities and how it will be monitored by the plan
● Through a pre-delegation audit and annual oversight audits thereafter, assess the
delegate's ability to fulfill its responsibilities, including administrative capacity, technical
expertise, and budgetary resources
● Maintain written oversight procedures in place to ensure providers are fulfilling all
delegated responsibilities; delegated organizations and providers must provide quality
metrics for review by the QI Committee, including but not limited to periodic reporting of:
o Complex case management summary
o Utilization management (UM)
o Performance improvement initiatives, findings, and corrective actions
Preventive Health and Wellness Initiatives
Oscar’s goal is to meet and exceed all the highest clinical and customer quality standards and
reporting requirements, specifically the utilization and quality measures of HEDIS and the CAHPS
survey.
46
Population Health Management
Oscar offers a variety of programs designed to keep members healthy, improve clinical outcomes
across settings, support members with emerging clinical risk and support members with multiple
chronic illnesses. These programs cover a range of areas such as: Prevention and Screening,
Concierge Case Management, Discharge Planning and Complex Case Management. Our
Complex Case Management (CCM) program supports Oscar members in managing chronic
conditions and assists them in minimizing barriers and navigating the healthcare system.
Enrollment into Oscar’s CCM program involves a comprehensive assessment of the member’s
condition, determination of available benefits and resources, and development and
implementation of a case management plan with performance goals, monitoring and follow-up.
Depending on the needs of your patient, they may qualify for a number of Oscar’s Population
Health Programs. To refer an Oscar member or obtain more information on Oscar’s Population
Health programs, call 1-855-OSCAR-55.
Oscar Livongo Diabetes Program
Beginning in 2022, Oscar is offering a unique benefit plan - Silver Simple - For Diabetes (see
“Diabetes Care Plan” section of this Manual for more information). Oscar members enrolled in
this plan have access to Livongo and may receive wellness incentives for their participation.
Livongo’s program offers coaching along with a smart cellular-enabled blood glucose meter
(paired with a mobile app) to support improved outcomes for diabetes and also lower cost of
care. Livongo’s specific services include at no cost:
● Smart Glucose Meter and connected mobile app which provides real-time feedback on
glucose readings and health nudges to drive action for members to improve monitoring
and outcomes
● Coaching with certified diabetes educators around self-management, nutrition, activity and
routine monitoring
● 24/7 remote monitoring for extreme high/low blood glucose readings and support for
members
● Free supplies - lancets, test strips and control solutions for the smart glucose meter while
on the Livongo program
Diabetic members enrolled in the Diabetes Care Plan will need to register for Livongo and will be
provided information to enroll via Livongo’s website. Engagement with Livongo is not a substitute
for the sound medical judgment of a member’s doctor. The final decision regarding any treatment
or services is between the patient and their healthcare provider.
Health Management and Education
Oscar engages in health education to equip members with tools and resources to stay healthy,
improve knowledge about chronic conditions and their treatment, learn behaviors for better
self-management, and promote prevention and early detection of illnesses. Education efforts
include telephone outreach, targeted online content, member engagement through Oscar’s
47
mobile app and website, and other tactics. We evaluate outcomes using several mechanisms,
including but not limited to HEDIS measures, utilization statistics, pharmacy data, and program
participant surveys.
Member and Provider Satisfaction
Member satisfaction is a high priority and may be assessed by several sources, including but not
limited to: Satisfaction surveys and appeals and grievances. Member complaints and appeals are
assessed by reason category, provider, region, and delivery system.
Provider satisfaction may be assessed by satisfaction surveys and direct feedback offered by
provider organizations. Satisfaction issues are categorized and assessed by severity and
prevalence of the issue. Issues not meeting standards or performance benchmarks are identified
and a Corrective Action Plan (CAP) for resolution and correction is implemented.
Potential Quality Issues
Definitions
Potential Quality Issue (PQI): A suspected deviation from provider performance, clinical
care, or outcome of care which requires further investigation to determine if an actual
quality of care issue exists.
Quality of Care (QOC) Issue: A confirmed adverse variation from expected clinician
performance, clinical care, or outcome of care, as determined through the PQI process.
Quality of Service (QOS) Issue: A confirmed adverse variation that causes dissatisfaction
and a poor experience in the delivery of healthcare services. Clinician or provider is any
individual or entity engaged in the delivery of healthcare services licensed or certified by
the state to engage in that activity, if licensure or certification is required by state law or
regulation.
Corrective Action Plan (CAP): A plan approved by the appropriate quality improvement
committee to help ensure that a related quality issue does not occur in the future. CAPs
contain clearly stated goals and timeframes for completion.
Process
Oscar has a systematic method for the identification, reporting, and processing of PQIs to
determine opportunities for improvement in the provision of care and services to Oscar members
and to direct actions for improvement based upon the frequency and severity of the PQI.
It is our policy to accept a PQI referral through a variety of sources. These include but are not
limited to: Internal referrals from Grievances and Appeals; an Oscar member; an Oscar provider;
an Oscar staff member; an affiliate.
All PQIs that are identified will be tracked in the PQI log for the purposes of monitoring patterns
to identify any potential trends or any significant sentinel events.
48
All information obtained during and used in a quality of care investigation will be held in strict
confidence, according to the Plan confidentiality policies and in accordance with all relevant state
and federal peer review laws and regulations.
A designated medical professional reviews all referred PQIs to identify whether a true Quality of
Care or Quality of Service issue exists after which the case will be assigned a severity score.
Some cases will be referred to the Peer Review and Credentialing Subcommittee based on our
policy. Based on review by the Peer Review and Credentialing Subcommittee, a provider may be
placed on a CAP or may be required to submit a CAP. The CAP will request follow-up and
evidence from the provider in question to demonstrate that the corrective actions have been
implemented as specified.
All PQI outcomes are trended on a continuous 36 month basis. Any identifiable trends, regardless
of outcome to the member, will be referred to the Quality Improvement Committee on a quarterly
basis for potential action or educational opportunities.
Reporting
To report a Potential Quality Issue (PQI), you may complete the PQI Referral Form, which can be
accessed in the “Forms” section of www.provider/hioscar.com/resources. This form can be
submitted via:
Fax:
1-888-732-0625
Email:
quality@hioscar.com
Mail:
Oscar Health, Inc. Quality Improvement Program
P.O. Box 52146
Phoenix AZ, 85072–2146
Clinical Practice and Preventive Health
Guidelines
Overview
Clinical practice guidelines, preventive health guidelines, and other internal criteria provide
direction and standards for preventive, acute, and chronic care health services relevant to
Oscar’s enrolled membership. Clinical practice guidelines are reviewed against UM criteria and
member education materials to ensure consistency and alignment with appropriate medical
49
recommendations.
Oscar is committed to the philosophy that evidence-based guidelines are known to be effective
in improving health outcomes. Oscar compiled a group of recognized resources that promulgate
evidence-based clinical practice guidelines (see below).
Preventive Care Guidelines
U.S. Preventive Services Task Force: The U.S. Preventive Services Task Force (USPSTF)
issues recommendations on screening, counseling, and preventive medication topics and
includes clinical considerations for each topic. Includes guidelines for adults 20-64 and
65+ years as well as children 2-19 years. For details:
www.uspreventiveservicestaskforce.org.
Advisory Committee on Immunization Practices (AICP): Medical and public health
experts who develop recommendations on the use of vaccines in the civilian population of
the United States. The recommendations stand as public health guidance for safe use of
vaccines and related biological products. Includes guidelines for children under 24
months. For details: www.cdc.gov/vaccines/hcp/acip-recs/index.html.
The American College of Obstetricians and Gynecologists (ACOG): Decision support
resources grounded in scientific evidence from the premier professional organization
dedicated to the improvement of women’s health. For details: www.acc.org/guidelines.
American Academy of Pediatrics: Evidence-based decision-making tools for managing
common pediatric conditions. Includes guidelines for children from birth to 19 years. For
details: www.pediatrics.aappublications.org/current_policy.
Acute / Chronic Medical Condition Guidelines
American College of Cardiology: Framework of evidence-based clinical statements and
guidelines developed by leaders in the field of cardiovascular medicine. For details:
www.acc.org/guidelines.
American Diabetes Association: Standards, guidelines and clinical practice
recommendations for healthcare professionals who care for people with diabetes. For
details: www.professional.diabetes.org/content-page/practice-guidelines-resources.
American College of Physicians: American College of Physicians resource for clinical
practice guidelines addressing screening, diagnosis and treatment of diseases relevant to
internal medicine and its subspecialties. For details:
www.acponline.org/clinical-information/guidelines.
50
Behavioral Health Guidelines
Professional Resources for Behavioral Health: Optum is the contracted Managed
Behavioral Health Organization for Oscar. Optum provides best practice guidelines for the
screening, diagnosis, and treatment of mental health conditions and substance use
disorders. For details:
www.providerexpress.com/content/ope-provexpr/us/en/clinical-resources.html.
Medical Records and Standards
Medical Record Content
Complete medical records requested for the purpose of claim payment must include the content
outlined in the earlier “Requests for Additional Information” section in this manual.
Oscar has standards that require providers and facilities to maintain medical records in a manner
that is current, organized, and facilitates effective and confidential member care and quality
review. Oscar performs medical record reviews to assess whether network primary care
physicians (PCPs) are compliant with current medical record standards:
● Every page in the record contains the patient name or ID number
● Documentationofallergies orNoKnown DrugAllergies(NKDA)andadversereactions are
prominently displayed in a consistent location
● All presenting symptom entries are legible, signed, and dated, including phone entries
○ Dictatednotesshouldbesignedorinitialledtosignifyreview
○ Ifinitialled,signature sheet for initials are noted
● The important diagnoses are summarized and highlighted
● A problem list is maintained and updated for significant illnesses and medical conditions
● A medication list or reasonable substitute is maintained and updated for chronic and
ongoing medications
● History and physical exam identify appropriate subjective and objective information
pertinent to the patient’s presenting symptoms, and treatment plan is consistent with
findings
● Pastmedicalhistoryisdocumentedincludingsignificantillnesses,accidents,and
operations, and prenatal and birth information for paediatric members
● Each visit notation includes the following:
○ Subjective Data: Chief complaint (or reason for visit)
○ Objective Data: Focused (problem-specific) physical examination
○ Assessment: Diagnosis or impression
○ Plan: Treatment plan, goals
● Laboratory tests and other studies are ordered, as appropriate, with results noted in the
medical record (note: the clinical reviewer should see documentation of appropriate
follow-up recommendations and / or non-compliance to the care plan)
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○ Follow-up care is scheduled for abnormal findings
● Referrals to specialists are clearly documented
○ Follow-up report received and acknowledged when referred specialist care was
obtained
● Documentation of Advance Directive or Living Will or Power of Attorney discussion in a
prominent part of the medical record for adult patients is encouraged
○ Should the member decline an Advance Directive, documentation of the member
decision shall be documented
● Continuity and coordination of care between the PCP, specialty physician(s) including:
○ BH specialty) and/or facilities if there is reference to referral or care provided
elsewhere
○ The clinical reviewer will look for a summary of findings or discharge summary in
the medical record; examples include, but are not limited to: Progress notes /
reports from consultants, discharge summary following inpatient care or outpatient
surgery, physical therapy reports, and home health nursing / provider reports
● Age appropriate routine preventive services / risk screenings are consistently noted (e.g.
childhood immunizations, adult immunizations, mammograms, pap tests) or the refusal by
the patient, parent or legal guardian, of such screenings/immunizations in the medical
record
● Medical records are stored securely and only authorized personnel have access
● There is evidence of annual staff confidentiality training
● Evidence that the member was informed of their rights and responsibilities as a member
● Evidence that the record was created contemporaneously with submission of the claim
and include dates and signatures on any late entries, addendums, or corrections
Pharmacy Services
Overview
Oscar provides access to generic, brand, and specialty drugs through a network of pharmacies,
infusion centers, hospitals, and outpatient provider sites. We partner with Pharmacy Benefit
Manager (PBM) CVS/Caremark to manage the pharmacy network, process claims, and support
general pharmacy benefit operations. Oscar retains responsibility for maintaining the drug
formulary through a Pharmacy and Therapeutics Committee (P&T) committee composed of
healthcare providers in various settings. Oscar also reviews all prior authorizations, peer-to-peer
requests, appeals, and non-formulary requests submitted by providers. Please see below for
information on how to navigate the formulary and submit a prior authorization, appeal, or
non-formulary exception.
Formulary Management
Oscar maintains a list of covered medications, called the Formulary, that is reviewed and updated
on a regular cycle. The Formulary includes medications in most therapeutic classes but may not
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necessarily include all dosage forms of a given prescription drug (e.g. oral tablets, liquids, topical).
The P&T committee provides clinical expertise when determining a drug’s place in therapy and
provides input on standard of care and real-world patient-centered outcomes. The committee
meets regularly and oversees the drug review process to ensure that clinical efficacy, safety, and
quality are appropriately considered for all drugs.
While Oscar’s formulary generally stays consistent between plan years, medications are added or
removed from the formulary on an annual basis and rules for coverage may change as well. Oscar
always ensures uniformity among all individuals in a given plan type when changes to the
formulary occur. When a change does occur, advanced notice is provided to members, healthcare
providers, and the Insurance Commissioner in accordance with federal and state specific law. To
receive coverage for a formulary medication, members must have a health care provider prescribe
the medication and the medication must be determined by Oscar to be medically necessary.
The Formulary contains utilization management rules for coverage such as prior authorization,
step therapy and quantity limits. To request coverage for a medication not listed on the Oscar
Formulary, members or their health care providers may submit a request to us. If you have a
question regarding whether a drug is on the Formulary, please see the most updated version of
the Formulary here: www.hioscar.com/forms or call us at 1-855-OSCAR-55.
Prior Authorizations and Non-Formulary Exceptions
Some drugs on Oscar’s formulary require prior authorization before Oscar will pay for the drug at
the pharmacy. A team of pharmacists and physicians review these requests to ensure that the
most clinically appropriate and cost-effective drugs are being prescribed. When a pharmacy
notifies you that a drug requires prior authorization, you can initiate the authorization through one
of the methods listed at the end of this section.
If you are prescribing a drug that is not on Oscar’s Formulary, please review the Formulary first to
determine if an alternative drug is clinically appropriate. If not, you can submit a non-Formulary
exception request via the methods below. For all prior authorization and non-Formulary
exceptions, medical records are required to verify the information attested to on the prior
authorization form. If Oscar’s clinical reviewer needs additional information, they will reach out to
your office with the specific information needed to render a decision. If your request is denied, you
may have a peer to peer discussion regarding the decision with a clinical reviewer at Oscar. If you
disagree with this decision, you may request an appeal to have the decision re-reviewed by a
different reviewer, or you may request an external appeal to have the case reviewed by a state
assigned reviewer. You may always request a free copy of the actual benefit provision, guideline,
protocol or other similar criterion on which our decision was based. You may also request
reasonable access to, and copies of, all of the case documents.
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You can submit a prior authorization, non-Formulary exception, or appeal request by downloading
a form here: www.hioscar.com/forms and submitting through the following methods:
Electronically:
CoverMyMeds: www.covermymeds.com
Fax:
1-844-814-2259 (Specialty Drugs)
1-844-814-2258 (Non Specialty Drugs)
Phone:
1-855-OSCAR-55
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