Oscar Insurance Company (Texas) in-network claim denial rate: 18.3%

In the CMS Transparency in Coverage file for plan year 2025, Oscar Insurance Company reported denying 337,877 of 1,845,992 in-network claims (18.3%) in Texas, from 2023 claims. 52.3% of internal appeals were overturned (12,338 of 23,598). That is the 10th highest reported rate of 14 ranked issuers in Texas; the state median is 23.1%.

Denial rate

18.3%

337,877 of 1,845,992 claims

Appeals overturned

52.3%

12,338 of 23,598 filed

External review overturned

27.6%

24 of 87 filed

Prior file (plan year 2024, 2022 claims): denial rate 11.7% (498,535 of 4,277,370); appeal overturn rate 47.9%.

Compared with Texas and the national median

Measure	Oscar Insurance Company	Texas median	National median
In-network denial rate	18.3%	23.1%	18.3%
In-network claims received	1,845,992	—	—
Internal appeals filed	23,598	—	—
Internal appeal overturn rate	52.3%	54.4%	41.7%
External reviews filed	87	—	—
External review overturn rate	27.6%	35.9%	0.0%
Out-of-network denial rate	49.1%	—	—

Medians are across issuers with at least 1,000 in-network claims received in the same file (Texas: 14 issuers; national: 176 issuers in 32 states). Plan year 2025 file, 2023 claims.

Read these numbers carefully

Reporting lag: the CMS public-use file for a plan year reports claims from two plan years earlier (the PY2025 file carries 2023 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 2025; data dictionary. Issuer's own claims-payment policy page: https://hioscar.com/tx_tic_2025.

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.

Plans in this filing (65)

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	117,316
20069TX0100006	EPO	Silver	32,161
20069TX0100024	EPO	Bronze	42,028
20069TX0100025	EPO	Silver	48,133
20069TX0100050	EPO	Bronze	29,273
20069TX0100052	EPO	Silver	17,792
20069TX0100053	EPO	Gold	51,174
20069TX0100055	EPO	Gold	n/a
20069TX0100056	EPO	Gold	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
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
20069TX0510040	HMO	Silver	n/a
20069TX0510041	HMO	Silver	n/a
20069TX0510050	HMO	Silver	n/a
20069TX0510051	HMO	Silver	n/a
20069TX0510052	HMO	Silver	n/a
20069TX0510053	HMO	Silver	n/a
20069TX0510054	HMO	Silver	n/a
20069TX0510055	HMO	Gold	n/a
20069TX0510056	HMO	Gold	n/a
20069TX0510057	HMO	Gold	n/a
20069TX0510058	HMO	Silver	n/a
20069TX0510059	HMO	Silver	n/a
20069TX0510060	HMO	Silver	n/a
20069TX0510061	HMO	Silver	n/a
20069TX0510062	HMO	Silver	n/a
20069TX0510063	HMO	Gold	n/a
20069TX0510064	HMO	Gold	n/a
20069TX0510065	HMO	Gold	n/a
20069TX0510066	HMO	Silver	n/a
20069TX0510067	HMO	Silver	n/a
20069TX0510068	HMO	Silver	n/a
20069TX0510069	HMO	Silver	n/a
20069TX0510070	HMO	Silver	n/a
20069TX0510071	HMO	Gold	n/a
20069TX0510072	HMO	Gold	n/a
20069TX0510073	HMO	Gold	n/a
20069TX0510074	HMO	Silver	n/a
20069TX0510075	HMO	Silver	n/a
20069TX0510076	HMO	Silver	n/a

Showing 60 of 65 plans; all rows are in the CSV download.

Questions

What counts as a "denied" claim in Oscar Insurance Company's 18.3% rate?

Every in-network claim the issuer reported as denied in the 2023 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 2023 when the file is for plan year 2025?

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 (23.1%) 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, 52.3% of internal appeals to this issuer were overturned (12,338 of 23,598). 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 2025, 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.