oscar HMO Referral Policy User Manual
- June 2, 2024
- Oscar
Table of Contents
oscar HMO Referral Policy
Product Information
Specifications:
- Product Type: HMO Health Plan
- Provider Network: In-network specialists within the plan’s network
- Referral Process: PCP-guided care with referrals required for specialist visits
Product Usage Instructions
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PCP Selection and Referrals:
Members on HMO plans are encouraged to select a Primary Care Provider (PCP) during enrollment. If a PCP is not selected, one will be assigned by Oscar. Members can change their PCP at any time during the plan year. -
Submitting Referrals:
Referrals must be submitted through the Oscar portal at provider.hioscar.com/. Only a member’s PCP or PCPs within the same provider group can submit a referral. Referrals will undergo a rapid review process and become effective immediately upon verification. -
Verification of Referrals:
Specialists must review referrals related to the member in the Oscar Portal to ensure coverage eligibility. While PCPs can recommend a specific in-network specialist, the referral is valid for all in-network specialists within that specialty. -
Validity of Referrals:
The PCP determines the number of visits and duration needed for each referral, up to the allowed maximum. Referrals are valid until the indicated end date or for the authorized number of visits. Unused visits are not valid after the end date.
Frequently Asked Questions
Oscar is growing! We are pleased to share Oscar’s plans to expand our product portfolio and health plan footprint beginning in the year 2025 to serve the expanding ACA population by adding a new HMO product. This will be a guided care plan that puts the primary care provider (PCP) in the driver’s seat as a partner in helping the member navigate their care journey.
We will provide training and education on specific rules applicable to all new plans and publish all updates in Oscar’s Provider Manual, which is currently available at hioscar.com/providers/resources. Provider Manual updates will include new changes for all Oscar plans as well as HMO-specific matters, such as referral or PCP requirements.
Do Oscar members need a PCP?
Members on HMO plans are encouraged to select a PCP during enrollment. Oscar will assign one if not selected initially.
Are referrals required for this HMO plan?
Yes, referrals for specialist visits are required under HMO gated plans. Referral exceptions include eligible services for OBGYN, emergency care, urgent care, behavioural health, and services for which applicable laws do not allow a referral requirement. Not obtaining a required referral for a service means that the service will not be covered. To note, the specialist referral requirement does not replace notification and/ or prior authorization requirements.
Who can submit referrals?
Only a member's PCP or PCPs within the same provider group can submit referral. Referrals received from other PCPs or specialists will not be considered valid; they must ask the member's PCP to submit a referral. In cases where a member reports being unable to access their PCP in a timely manner, Oscar may take steps to provide the member with access to an alternative referral source.
How should referrals be submitted?
Referrals must be submitted via the Oscar portal at provider.hioscar.com/ and will undergo a rapid review process. Referrals are effective immediately once verified and will be viewable in the portal system.
Where can a member's referral be verified?
Specialists must review referrals related to the member in the Oscar Portal when verifying the member's eligibility to ensure that the visit will be covered.
Will a referral cover all in-network specialists in that specialty?
While PCPs can list a recommendation for a specific in-network specialist when submitting the referral, the referral will be valid for all in-network specialists within that specialty.
How long is the referral valid?
The PCP 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 through the indicated referral end date. Any unused visits are not valid after the end date. If a referral is no longer valid, but the member requires additional care, the member or specialist must contact the member's PCP to request a new referral.
Will referrals carry over from previous health plans?
No, referrals from a member's previous health plan will not carry over to Oscar's plan.