Oscar Health MA

Contract: H2222 · Plan type: HMO

Evidence lead: Ranks four through six · High appeal-filing share

Oscar Health MA: Appeals followed a large share of denials

626 appeals equal 15.0% of this contract's recorded denials. That is rank #4 of 37 for filing share. The ratio reports aggregate activity; it cannot reveal why an appeal was or was not filed, whether the underlying cases were comparable, or what happened outside the reporting window.

Ranks four through six · High appeal-filing share

Appeals followed a large share of denials

626 appeals equal 15.0% of this contract's recorded denials. That is rank #4 of 37 for filing share. The ratio reports aggregate activity; it cannot reveal why an appeal was or was not filed, whether the underlying cases were comparable, or what happened outside the reporting window.

Bottom-seven record · Lower overturn-rate cohort

One of the ten lowest appeal overturn rates

62.0% of filed appeals were overturned, placing this record in the lowest-rate tier. Its overturn-rate rank is #33 of 37. The denominator is filed appeals, not all authorization requests. The percentage therefore describes reviewed appeals and must not be read as an individual outcome forecast.

Bottom-seven record · Narrow reversal reach

Overturned appeals covered a small share of denials

9.3% of the plan's denials were ultimately overturned through the appeals counted here. The cross-contract rank is #33 of 37. This derived measure combines appeal filing and outcome, so it supplies scale context but does not identify clinical reasons, administrative errors, or coverage rules.

Bottom-seven record · Smaller request-volume cohort

One of the narrower authorization records

The source records 43,000 requests here, placing the contract in the smallest-volume tier. Its request-volume rank is #32 of 37. Volume shows the denominator behind approvals and denials; it is not a measure of plan quality, membership, benefit breadth, price, or future coverage decisions.

Ranks seven through ten · Higher denial-rate cohort

A top-ten denial rate in this source set

Oscar Health MA's 9.7% denial rate is in the highest group of the comparison. The exact rank is #8 of 37. This is aggregate prior-authorization activity for the reporting window, not a probability that a particular service, drug, or beneficiary request will be denied.

Prior Authorization Scorecard

PA Requests
43,000
PA Denial Rate
9.7%
Appeals Filed
626
Appeal Overturn Rate
62.0%

Detailed Metrics

Metric Value
Prior Authorization Requests 43,000
PA Approved 38,829
PA Denied 4,171
Appeals Filed 626
Appeals Overturned 388
Source: CMS Office of Inspector General report OEI-09-22-00380; KFF 2023 Medicare Advantage analysis. Verify with HHS OIG → · CMS.gov →
Sources, caveats, and related notes for Oscar Health MA
What does Oscar Health MA's overturn rate mean? Of the appeals filed after denials in this source record, 62% were overturned (388 of 626 filed appeals, not all 4,171 denied requests).
This data is for informational purposes only and does not constitute medical, financial, or insurance advice. Contact CMS or your plan for coverage decisions. Data from CMS OIG and KFF Medicare Advantage analysis.

Data: CMS OIG OEI-09-22-00380 and KFF 2023 Medicare Advantage analysis. Not affiliated with CMS. ← All MA plans

Read our methodology - how this data is sourced, computed, and verified.

Primary data: U.S. Department of Health & Human Services, Office of Inspector General, Medicare Advantage Encounter Data (Report OEI-09-22-00380, 2024). Secondary data: Kaiser Family Foundation 2023 Medicare Advantage Prior Authorization analysis. Methodology and editorial review by PlainInsurer, see methodology.