Frequently asked questions

The best way to reach Oscar is by calling our Provider Services team at (855) 672-2755, option 4.

Here’s how to check on a provider’s credentialing status:

• Go to provider.hioscar.com/provider-credentialing-status (opens in new tab)
• Enter the NPI & CAQH ID for the provider.

If you have any questions or concerns about the credentialing process, just send us a message at credentialing@hioscar.com and we’ll look into it.

Our credentialing process for new providers takes up to 45 days after we receive all required applications and documents. You can check your status on our credentialing tool. Or, right in our directory at hioscar.com/search. If you’re not in the directory after 45 days, just send us a message at credentialing@hioscar.com and we’ll look into it.

It takes about 2 weeks to show up in the provider directory. And, if your credentials were approved by a certain date, it’s possible you’ll be in the directory by the Open Enrollment Period.

We’re here for you. Just message us at credentialing@hioscar.com and include your name and NPI. We’ll look into things and get back to you within 3 business days.

Providers should submit referrals for TX Guided Care HMO members through the Oscar portal for review. Referrals are active immediately upon validation and can always be viewed in the Oscar portal.

Yes, a valid referral given to a TX Guided Care HMO member will cover all in-network specialists within the referred specialty. Members can see any in-network specialist in that given specialty with a valid referral. This is true, even if the referring PCP recommends a specific specialist.

The “pending” status means that a non-assigned or selected PCP (or PCP within the same group) submitted the referral.

Now what? Have the member switch their assigned PCP to the provider that submitted their referral. Or have them get a new referral from the PCP listed on their account.

Yes. Referrals for specialist visits are required for members with TX Guided Care HMO plans. Members must get a referral from their selected or assigned PCP (or a PCP within the same provider group). If a member doesn’t get a referral for a service beforehand, it unfortunately won’t be covered by their plan.

Referral exceptions include eligible services for OBGYN, emergency care, urgent care, behavioral health, and anything that doesn't allow a referral requirement.

Note: Specialist referral requirements don’t replace notification and/or prior authorization requirements.

No, you can’t change a member’s assigned PCP for them. They must change their own assigned PCP right in their Oscar account or by calling Member Services.

Oscar encourages members with Texas Guided Care HMO plans to select their PCP during enrollment. If a member doesn’t select one by the start of the plan year, Oscar matches them with a PCP. Members can change their PCP at any time, of course.

You can see a member’s assigned PCP on their member profile — right in the Oscar Provider Portal. To find a member, search with their Oscar ID or their first name, last name, and DOB.

You can check to see if a member has a valid referral by going to their member profile right in the Oscar Provider Portal. The referrals tab will quickly let you see the status of any referral. Just remember this only applies to members with Guided Care HMO plans that require referrals.

The PCP who submits the referral determines the number of visits and/or the duration needed for each referral – up to the allowed maximum(s). Referrals are only valid for the authorized number of visits or until the referral end date.

If a member requires additional care after their referral is no longer valid, the member or specialist must contact the member’s PCP to request a new referral.

First, reach out to your Organization Administrator to see if they can help you access your portal account at provider.hioscar.com. If you still need support, just call your Oscar Provider Services team at (855) 672-2755. We’re here to help.

To submit a referral, you’ll need a few things:

• The referring provider’s info, which you can find by searching by name or by NPI
• The specialty you'd like to refer the member to
• The referral time range or the number of referral visits
• [optional] Any specific in-network specialist you’d like to recommend

A TX Guided Care HMO member’s referral can be verified in the Oscar portal. Specialists must review referrals to verify the member’s eligibility and coverage.

To submit a referral for a TX Guided Care HMO member, log into the Oscar Provider Portal and go to the member’s profile page. From there, click Submit Referral on the top right and get started. That’s it!

Only a TX Guided Care HMO member’s PCP (or a PCP within the same provider group) can submit a valid referral for a member. Referrals received from other PCPs or specialists are not considered valid.

If a member can’t access their PCP in a timely manner, Oscar may help the member access an alternative referral source.

When roster submissions are sent to Oscar, providers indicate if they’re PCPs. If you’re incorrectly listed as a PCP, reach out to your roster administrator for clarification or to make changes. For more information on the roster submission process, visit hioscar.com/provider-rosters.

No, referrals from a TX Guided Care HMO member’s previous health plan do not carry over to any of Oscar’s plans.

Here’s how to find our reimbursement policies:

• Go to Oscar Provider Manual.
• Select your state from the top left hand dropdown.

The reimbursement policies listed include diagnosis and procedure code billing, and payment guidance. Plus, they may help you see how a claim has been processed.

Yes! Use this enrollment form (opens in new tab) to enroll in both ACH/EFT and ERA/835 or to change your enrollment. Just follow the steps on the form to complete your enrollment.

Currently, we don’t offer direct reimbursement for claims submitted by healthcare providers outside of the United States. Instead, we encourage our members to contact Oscar directly to understand their international coverage benefits and the reimbursement process for any emergency care they receive internationally.

Here’s what Oscar members can do for reimbursement of emergency care received outside of the U.S:

• Go to our Forms & Notices page
• Choose their state and plan year
• Download a Member Claim form

They’ll need to include:

• An itemized copy of the bill
• Proof of payment
• Medical records for their visit

Any international claim documents in other languages don’t need to be translated into English. Additionally, international claims don’t require TIN, NPI, CPT, or ICD-10 codes.

That’s great news! If you’re an out of network provider and you'd like to join the Oscar network, just submit this request form.

We get a lot of submissions and each one is assessed based on current network provider needs, so it may take us several business days to respond. Hang tight, and we’ll be in touch.

Payment settings for your organization are managed by Optum Financial Inc. and ECHO Health Inc.

You’ll need to use ECHO’s online tools to enroll, make changes to your preferences, and view certain details of payments you receive.

Quick links:

• Oscar EFT enrollment
• Universal EFT enrollment
• View Optum dispersed payments
• View / manage virtual credit card payments
• Learn more

If you find that you must change your ERA enrollment, ECHO Health Inc. can be contacted at: (440) 835-3511.

Different types of profiles have different permissions within the Oscar Provider Portal. So, if you’re not seeing something you think you should be seeing, ask your Portal Administrator to take a look at your permissions.

The Portal Admin can enable more permissions in your profile, if needed.

If you need help identifying the admin of your existing portal account, just call our Provider Services team.

Here are a few things you can do:

• Check their permissions: Navigate to the user's profile (Menu > Manage Organizations > Select the appropriate organization > Select the user in the Staff section then scroll to "Permissions"). Review and select any additional permissions your team member needs.
• Validate feature access: If the user's profile has the correct permissions enabled but they still can’t see the information they need, check their team assignment and set up to verify that they have access to the specific tax ID number (TIN) and National Provider Identifier (NPI) associated with the account.

The person with this role in the site should be a person you trust to cover all the administrative needs for your organization.

Portal Administrators can:

• Add TINs to a portal account
• Create Teams (to limit access to specific TINs or NPIs)
• Invite, approve, and cancel other portal users, as needed
• Adjust permissions within the site to grant or revoke access to other staff
• Create additional Portal Admins

Your Portal Administrator for the portal should be a person you trust to cover all the administrative needs for your organization, and manage your main account. It’s totally up to you. But typically, the Portal Administrator is your primary office manager or in-house biller. For smaller practices, it could also be a provider or nurse.

Just keep in mind that Portal Administrators have the most permissions within the site. In addition to creating and configuring the portal, Portal Admins also invite, approve, and cancel portal users in your group, as needed. Once your portal account is set-up, additional Admins can be assigned to support user access.

If you need help identifying the admin of your existing portal account, just call our Provider Services team.

We encourage members to select their own Primary Care Provider (PCP) to increase patient engagement, drive improved health outcomes, and continue to drive high quality care. We do this through our Primary Care Provider Assignment or PCP Assignment program.

If a member doesn’t select a PCP within 30 days after their plan goes into effect, we’ll assign a PCP to them. Then, they can always change to a different PCP if they prefer. We do our best to match them with someone who will offer what they need.

The states where we don’t automatically assign PCPs are AL, MS, NE, NJ, NY, OK, PA, TN, VA.

We strongly encourage providers to adhere to the industry standard NUCC codes but we will accept specialty names if necessary.

We strongly encourage providers to use Oscar’s new Standard Roster Template; however, you may use alternative formats as long as they are aligned with the expectations, delineated below.

Yes, our provider directory will still recognize you as a PCP but you will not be eligible for automatic assignment of members.

No, you do not. You can have less than five languages, but should not have more than five. If you need to list more than 5 languages, then your provider should be duplicated onto a new row where you may list an additional 5 languages. You may continue this process until you have all necessary languages documented.

No, English does not need to be listed in a language column.

You may enter the letters “Y”/ “N”, or the full words “Yes/ “No”.

Yes, English is a default language for all contracted providers.

NUCC codes corresponding to the following specialties are considered PCP. Additional NUCC codes may be accepted based on state-specific PCP definitions:

• Adolescent Medicine
• Family Medicine SCP
• General Pediatric Internal Medicine
• General Practice Medicine
• Geriatrician
• Internal Medicine SCP
• Primary Care Nurse Practitioner
• Virtual Primary Care
• Adolescent Medicine Nurse Practitioner
• Adult Health Nurse Practitioner
• Community Health Nurse Practitioner
• Family Nurse Practitioner
• Gerontology Nurse Practitioner
• Gynecology
• Internal Medicine Nurse Practitioner
• Medical Physician Assistant
• Nurse Practitioner
• OBGYN Group
• OBGYN Physician Assistant
• Obstetrics
• Obstetrics & Gynecology Nurse Practitioner
• Obstetrics and Gynecology
• Pediatrics Nurse Practitioner
• Physician Assistant
• Women's Health Nurse Practitioner

Payment settings for your organization are managed by Optum Financial Inc. and ECHO Health Inc.

You’ll need to use ECHO’s online tools to enroll, make changes to your preferences, and view certain details of payments you receive.

Quick links:-

• Oscar EFT enrollment
• Universal EFT enrollment
• View Optum dispersed payments
• View / manage virtual credit card payments
• Learn more

If you find that you must change your ERA enrollment, ECHO Health Inc. can be contacted at: (440) 835- 3511.

When setting up your bank account, you may be asked to enter Oscar’s ACH number or origin ID. These numbers will vary based on your state. Here are the numbers for New York, Texas, and California:

Oscar NY - 9000020110 Oscar TX - 9000020112 Oscar CA - 9000020113

First, reach out to your organization’s office manager and check if your group has already set up an Organization Administrator account. If so, they can send you an invite to set up your own account.

If you’re the first person in your organization to create an account, follow these steps:

• Visit provider.hioscar.com.
• Select Create Account and register with an email associated with your organization.
• Then, follow the steps to create the account. If you’re the Organization Administrator for your group, you’ll need some information about your organization. Once you’re set up with your account, you can invite other teammates to create their own under your group.

To keep our members’ information safe, we do a quick verification process when you sign up for an account. We’ll only do it once just to confirm some details.

There are two ways to verify:

• Instant Verification (when you already have claims with us): If you have pre-existing adjudicated claims and payment information available with Oscar, you can verify your account instantly. If you see this option, we’ll ask you to enter information about two claims from the last 90 days. When you enter the correct information, your account will be verified right away. Just look out for an email from us with a link to confirm your account.
• Manual Verification: Just call our Provider Services team to have your account verified over the phone. We’ll be asking for your organization name, provider TIN, provider address, and provider NPI.

Providers and staff within the Oscar network can all create accounts on the Oscar Provider Portal. This step by step guide shows you how to set it all up.