Oscar Health Plan, Inc. claim denials in Arizona: the federal figures
Oscar Health Plan, Inc. denied 11.6% of in-network claims in Arizona — 54,197 claims out of 468,750. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to Oscar Health Plan, Inc.) | 422 | 47.6% |
| External review (independent) | — | — |
What Oscar Health Plan, Inc. denies most
The most common denial reason recorded for Oscar Health Plan, Inc. plans in Arizona is administrative reason. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Administrative reason | 19,128 | 32.1% |
| Service excluded from the plan | 17,104 | 28.7% |
| Benefit limit reached | 11,088 | 18.6% |
| Provider out of network | 4,761 | 8% |
| Referral required | 3,832 | 6.4% |
| Other reasons | 2,433 | 4.1% |
| Not medically necessary | 1,306 | 2.2% |
| Member not covered | 25 | 0% |
What to do if Oscar Health Plan, Inc. denied your claim
- Get the reason in writing. The denial notice must state the specific reason and the plan provision behind it. If it does not, request it — you are entitled to it free of charge.
- File the internal appeal. Generally within 180 days of the denial notice. Oscar Health Plan, Inc. overturned 47.6% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not Oscar Health Plan, Inc.. Generally you have 4 months from the final internal denial. This is the step nearly everyone skips.
- Ask for expedited review if waiting would seriously jeopardise your health. That timeline is days, not months.
Everything you need for your Oscar Health Plan, Inc. appeal: your two deadlines, the argument that fits your denial reason, an evidence checklist, and the external review request. Opens on screen the moment you pay.
Questions
Is Oscar Health Plan, Inc.'s denial rate high?
11.6% against a national average of 16% across the plans in this dataset. It is at or below average. A denial rate describes the insurer, not the merits of your claim.
Does appealing cost anything?
The internal appeal is free. External review is free under the HHS-administered federal process; where an issuer uses a contracted independent review organization or a state process, any fee is capped at $25.
Can Oscar Health Plan, Inc. ignore the external decision?
No. External review decisions are binding on the plan.