Oscar Insurance Company (Texas) in-network claim denial rate: 25.5%

In the CMS Transparency in Coverage file for plan year 2026, Oscar Insurance Company reported denying 764,285 of 3,001,076 in-network claims (25.5%) in Texas, from 2024 claims. 23.6% of internal appeals were overturned (9,061 of 38,325). That is the 3rd highest reported rate of 14 ranked issuers in Texas; the state median is 21.6%.

Denial rate

25.5%

764,285 of 3,001,076 claims

Appeals overturned

23.6%

9,061 of 38,325 filed

External review overturned

34.0%

176 of 517 filed

Prior file (plan year 2025, 2023 claims): denial rate 18.3% (337,877 of 1,845,992); appeal overturn rate 52.3%.

Compared with Texas and the national median

Measure	Oscar Insurance Company	Texas median	National median
In-network denial rate	25.5%	21.6%	19.0%
In-network claims received	3,001,076	—	—
Internal appeals filed	38,325	—	—
Internal appeal overturn rate	23.6%	52.5%	37.7%
External reviews filed	517	—	—
External review overturn rate	34.0%	45.1%	0.0%
Out-of-network denial rate	55.0%	—	—

Medians are across issuers with at least 1,000 in-network claims received in the same file (Texas: 14 issuers; national: 158 issuers in 32 states). Plan year 2026 file, 2024 claims.

Read these numbers carefully

Reporting lag: the CMS public-use file for a plan year reports claims from two plan years earlier (the PY2026 file carries 2024 claims). These are not this year's figures.
In-network only: the denial rate is in-network claims denied divided by in-network claims received. Out-of-network claims are shown separately where the issuer reported them.
"Denied" is broad: CMS counts every denial, including administrative denials, duplicate submissions, ineligibility, incorrect billing and partial denials, not only medical-necessity decisions.
Issuer level: CMS reports the counts once per issuer per state and repeats them on every plan row; plan-level counts, where present, list denials only, so no per-plan rate is computed.
Coverage: only issuers on the federally facilitated marketplace (HealthCare.gov states) report to this file. Employer plans, Medicare and Medicaid are not included.
No inference of intent: a higher rate can reflect the issuer's mix of claims, its billing rules or its membership as much as its coverage decisions. Compare with the state median and read the N.

Source: CMS Transparency in Coverage Public Use File (Health Insurance Exchange PUFs), plan year 2026; data dictionary. Issuer's own claims-payment policy page: https://hioscar.com/tx_tic_2026.

If Oscar Insurance Company denied your claim

A denial is a decision you can contest. Marketplace plans must give you at least 180 days to file an internal appeal and offer independent external review after it (45 CFR 147.136). The letter states your deadline.

Compare this issuer

Other issuers in Texas

Blue Cross Blue Shield of Texas 18.8%
Celtic Insurance Company 16.3%
UnitedHealthcare of Texas, Inc. 17.3%
Scott and White Health Plan 14.6%
Aetna Health Inc. (a TX corp.) 27.3%
Community Health Choice, Inc. 21.4%
Superior Health Plan 22.2%
Cigna HealthCare of Texas, Inc. 21.7%
CHRISTUS Health Plan 11.7%
Molina Healthcare of Texas, Inc. 24.0%
Sendero Health Plans, Inc. 21.5%
Moda Health Plan, Inc. 24.3%
Community First Insurance Plans 30.6%
Imperial Insurance Companies, Inc. 35.6%
Community Health Choice Texas, Inc. n/a
Harbor Health Insurance Company n/a
UnitedHealthcare Benefits of Texas, Inc. n/a
US HEALTH AND LIFE INSURANCE COMPANY n/a
Wellpoint Insurance Company n/a

Plans in this filing (100)

Where CMS lists plan-level denial counts they are shown; no plan-level rate is computed because the file does not give plan-level claims received.

Plan ID	Type	Metal	Plan-level denials (in-network)
20069TX0100005	EPO	Bronze	93,159
20069TX0100006	EPO	Silver	22,759
20069TX0100024	EPO	Bronze	55,063
20069TX0100025	EPO	Silver	49,913
20069TX0100050	EPO	Bronze	21,209
20069TX0100052	EPO	Silver	103,416
20069TX0100053	EPO	Gold	113,900
20069TX0100055	EPO	Gold	11,124
20069TX0100056	EPO	Gold	49,215
20069TX0100059	EPO	Bronze	n/a
20069TX0100064	EPO	Bronze	n/a
20069TX0100068	EPO	Bronze	n/a
20069TX0510001	HMO	Silver	n/a
20069TX0510002	HMO	Silver	n/a
20069TX0510003	HMO	Silver	n/a
20069TX0510004	HMO	Silver	n/a
20069TX0510005	HMO	Silver	n/a
20069TX0510006	HMO	Silver	n/a
20069TX0510007	HMO	Silver	n/a
20069TX0510008	HMO	Silver	n/a
20069TX0510009	HMO	Silver	n/a
20069TX0510010	HMO	Silver	n/a
20069TX0510011	HMO	Silver	n/a
20069TX0510012	HMO	Silver	n/a
20069TX0510013	HMO	Silver	n/a
20069TX0510014	HMO	Silver	n/a
20069TX0510015	HMO	Silver	n/a
20069TX0510016	HMO	Silver	n/a
20069TX0510017	HMO	Silver	n/a
20069TX0510018	HMO	Silver	n/a
20069TX0510019	HMO	Silver	n/a
20069TX0510020	HMO	Gold	n/a
20069TX0510021	HMO	Gold	n/a
20069TX0510022	HMO	Gold	n/a
20069TX0510023	HMO	Gold	n/a
20069TX0510024	HMO	Gold	n/a
20069TX0510025	HMO	Gold	n/a
20069TX0510026	HMO	Silver	n/a
20069TX0510027	HMO	Silver	n/a
20069TX0510028	HMO	Silver	n/a
20069TX0510029	HMO	Silver	n/a
20069TX0510030	HMO	Silver	n/a
20069TX0510031	HMO	Silver	n/a
20069TX0510032	HMO	Gold	n/a
20069TX0510033	HMO	Silver	n/a
20069TX0510034	HMO	Gold	n/a
20069TX0510035	HMO	Silver	n/a
20069TX0510036	HMO	Gold	n/a
20069TX0510037	HMO	Gold	n/a
20069TX0510038	HMO	Gold	n/a
20069TX0510039	HMO	Gold	n/a
20069TX0510040	HMO	Silver	n/a
20069TX0510041	HMO	Silver	n/a
20069TX0510042	HMO	Gold	n/a
20069TX0510043	HMO	Gold	n/a
20069TX0510044	HMO	Gold	n/a
20069TX0510045	HMO	Gold	n/a
20069TX0510050	HMO	Silver	n/a
20069TX0510051	HMO	Silver	n/a
20069TX0510052	HMO	Silver	n/a

Showing 60 of 100 plans; all rows are in the CSV download.

Questions

What counts as a "denied" claim in Oscar Insurance Company's 25.5% rate?

Every in-network claim the issuer reported as denied in the 2024 claims year, including administrative denials, duplicates, ineligibility, incorrect billing and partial denials, not only medical-necessity decisions. The figure is in-network claims denied divided by in-network claims received, exactly as reported to CMS.

Why is the data from 2024 when the file is for plan year 2026?

CMS's Transparency in Coverage public use file for a plan year reports claims data from two plan years earlier. This is the most recent issuer-level denial data CMS publishes for marketplace plans.

Does this predict whether my Oscar Insurance Company claim will be denied?

No. It is an aggregate across all of the issuer's marketplace plans in Texas. Your own claim depends on your plan, the service and the documentation. Compare the rate with the Texas median (21.6%) and read the N before drawing conclusions.

How do I appeal a Oscar Insurance Company denial?

Read the denial letter for the reason and the deadline, request the criteria and the claim file in writing, and file an internal appeal (at least 180 days on marketplace plans under 45 CFR 147.136). In the reporting year, 23.6% of internal appeals to this issuer were overturned (9,061 of 38,325). If the internal appeal fails, independent external review is available.

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Cite: Apellica Insurer Denial Report Cards, Oscar Insurance Company (Texas), plan year 2026, from the CMS Transparency in Coverage PUF. CC BY 4.0. Download the full table as CSV or read the methodology. Corrections: editorial@apellica.com.