CommercialAdministrativeMedium impact
PCP Assignment FAQ
Oscar Health·AZ, CA, FL, GA, IL, IA, KS, MI, MO, NE, NC, OH, OK, PA, TN, VA·Network
Effective date
Jan 1, 2023
We identified it
May 9, 2026
Summary
Oscar is expanding PCP (Primary Care Provider) assignment across 16 states, allowing members to select their own PCP or be auto-assigned within 30 days. Billing teams must understand that HMO plan members must have an assigned PCP to receive covered care, while EPO members can see any provider without PCP assignment. Practices need to verify PCP roster status with Oscar and ensure staff can guide patients on PCP selection and changes.
Action Required
REQUIREMENTS: By end of 2023 (or before accepting Oscar patients): (1) Billing team must verify that all providers at your practice are correctly listed as PCPs on the Oscar roster if applicable to their specialty—contact Oscar Provider Services at (855) 672-2755 if missing. (2) Update claim submission workflows to distinguish between Oscar HMO and EPO plan types: for HMO plans, only process claims if the patient's assigned PCP is your provider or within the same TIN; for EPO plans, process claims regardless of PCP assignment. (3) Front desk and clinical staff must direct Oscar patients to update their PCP assignment through their online account or Oscar concierge team if they wish to change providers. (4) Verify patient's digital ID card in Oscar Provider Portal to confirm current PCP assignment before processing visits, especially for HMO members. (5) Train billing staff on referral requirements: Oscar HMO plans may require referrals, while EPO plans do not—verify per patient's specific plan. Failure to apply correct HMO network rules may result in claim denials.