Organization Detail
Oscar Health
6 plans across 5 states · Exchange Plans
Oscar Health reported prior authorization metrics for 6 Exchange Plans plans across 5 states under CMS rule CMS-0057-F for calendar year 2025. Across those plans, Oscar Health processed 163,182 standard prior authorization requests. The average standard prior authorization denial rate was 17.5%, above the national average of 11.8%. When patients or providers appealed denied prior authorizations, 46.1% of appeals were overturned on average. Standard prior authorization decisions took an average of 2.5 days.
17.5%
Oscar Health Denial Rate
standard, avg across 6 plans
11.8%
National Average
all reporting plans
+5.7%
vs. National
above average
GA1 plan
| Plan | Requests | Approved | Denied | Appr % | Denial % ▼ | Appeals | Overturn % | Denied Appeal % | Appr Ext % | Denied Ext % | Mean Days | Med Days |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Oscar Health Georgia QHPExchange Plans | 66,300 | 55,933 | 9,508 | 85.7% | 14.3% | 1,165 | 48.6% | 51.4% | — | — | 2.0 | — |
IL1 plan
| Plan | Requests | Approved | Denied | Appr % | Denial % ▼ | Appeals | Overturn % | Denied Appeal % | Appr Ext % | Denied Ext % | Mean Days | Med Days |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Oscar Health Illinois QHPExchange Plans | 1,044 | 855 | 189 | 81.9% | 18.1% | 28 | 28.6% | 71.4% | — | — | 2.3 | — |
NJ1 plan
| Plan | Requests | Approved | Denied | Appr % | Denial % ▼ | Appeals | Overturn % | Denied Appeal % | Appr Ext % | Denied Ext % | Mean Days | Med Days |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Oscar Health New Jersey QHPExchange Plans | 11,402 | 9,234 | 2,199 | 81.0% | 19.3% | 291 | 52.6% | 47.4% | — | — | 2.9 | — |
TN1 plan
| Plan | Requests | Approved | Denied | Appr % | Denial % ▼ | Appeals | Overturn % | Denied Appeal % | Appr Ext % | Denied Ext % | Mean Days | Med Days |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Oscar Health Tennessee QHPExchange Plans | 31,002 | 27,369 | 3,386 | 88.3% | 10.9% | 417 | 54.9% | 45.1% | — | — | 1.5 | — |
TX2 plans
| Plan | Requests | Approved | Denied | Appr % | Denial % ▼ | Appeals | Overturn % | Denied Appeal % | Appr Ext % | Denied Ext % | Mean Days | Med Days |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Oscar Health Texas QHPExchange Plans | 53,434 | 40,542 | 12,897 | 75.9% | 24.1% | 1,977 | 49.1% | 50.9% | — | — | — | — |
| Oscar Health All Markets QHP (Federal CMS-0057-F)Exchange Plans | — | — | — | 81.7% | 18.3% | — | 42.7% | 57.3% | 91.2% | 8.8% | 3.7 | 1.8 |