Oscar Health was founded 14 years ago, in 2012. That’s not a lot of time when compared with other insurance companies. However, despite this, Oscar Health has become one of the most renowned and trustworthy payers in more than 20 states across the country.
Among its multi-state footprint, New York holds a special place because the company was founded there and is also headquartered in NY. As of now, the payer has over 3 million members under their insurance plans.
This is why many healthcare providers show interest in getting credentialed with Oscar Health in New York.
In New York, Oscar’s plans are underwritten by Oscar Insurance Corporation. Also, what’s interesting to note here is that since its inception, Oscar has participated in NY State of Health, the state’s Affordable Care Act (ACA) marketplace. What this means for providers is that Oscar Health provider credentialing in New York isn’t a straightforward process. Rather, it runs on a mix of its own standards and New York’s managed care credentialing law.
Don’t worry if you are confused about the process. We have created this guide to simplify the Oscar enrollment mechanism for you.
So, let’s start.
Oscar Health NY Provider Enrollment & Credentialing Requirements
Before you start with the Oscar Health New York credentialing application, you first need to gather the required documents. Both individual practitioners and group facilities can get credentialed. However, the requirements for both of them vary.
Here’s a quick look at how they are different:
Individual Practitioner Requirements
For individual practitioners, Oscar Health depends heavily on the Council for Affordable Quality Healthcare (CAQH) profiles. If you have a maintained CAQH profile, all you have to do is give Oscar Health authority as a participating organization. Then the company can directly pull the license, education, malpractice, and background information.
If you don’t have a CAQH profile, you must then submit a set of Oscar Health New York credentialing forms directly to the network team. With these forms, you have to provide the following documents:
- A completed and signed Practitioner Disclosure Questionnaire, covering licensure history, hospital privilege actions, malpractice claims, and criminal or civil history.
- Supporting documentation for any “yes” answer on the questionnaire.
- A work history summary or curriculum vitae (CV).
- A copy of current, valid malpractice coverage.
Group and Facility Requirements
On the other hand, if the practices already have a contract with Oscar Health New York and want to add more providers to it, they need to submit a roster listing each provider’s name, degree, NPI, tax ID, specialty, CAQH ID, and care locations. The documents required in this case are a bit more detailed compared to single practitioner applications.
Oscar Health New York credentialing requirements for organizational providers include:
- A completed Facility Credentialing Application.
- A copy of the facility’s operating license.
- Proof of general and professional liability coverage of at least $1,000,000 per occurrence and $3,000,000 in the aggregate.
- A copy of the facility’s accreditation, or a state or federal site survey inspection no older than three years, if the facility is not accredited.
New York State Oscar Health Credentialing Application Guidelines
Once you have gathered all the documents that we listed above, you can move on to the application process. Oscar Health New York credentialing application is a fairly simple process. Here’s a brief overview of the entire method:
Step 1
We have already explained above that if you are an individual practitioner, then you can save yourself from most of the hassle with a CAQH profile. So, the first step is to create and update the CAQH profile. Then give Oscar Health access as a participating organization. A lapsed re-attestation stalls everything downstream.
Step 2
If you can’t make a CAQH profile for some reason, then you have to submit the Practitioner Disclosure Questionnaire package directly to the New York network team. Similarly, practices submit a roster for each incoming provider, and facilities submit the separate Facility Credentialing Application along with proof of coverage and accreditation.
Step 3
Oscar Health’s credentialing work is delegated to a third-party verification partner that checks license status, education, malpractice history, and sanction databases against the submitted file. This review sits inside the standard 45-day window described above.
Step 4
Once a provider clears the review, Oscar Health adds them to its directory on a rolling basis. In addition to this, Oscar Health reports its full New York coverage area to the state Department of Health through the Provider Network Data System. Oscar Health does this every quarter for every county.
Key Challenges in Getting Credentialed with Oscar Health in NY
Here are some challenges that healthcare providers can face with Oscar Health New York insurance credentialing:
- The state’s 90-day response rule only protects providers joining an already-participating group practice. So, if you are a solo practitioner in NY and start an unaffiliated practice, you get no provisional in-network billing cushion.
- As we mentioned above, Oscar Health’s NY coverage area is reported by county every quarter. So, what you need to understand here is that individual approval and official network adequacy are not the same. You can clear the credentialing process, but you will still have to wait for the next quarterly filing before you can start serving and billing Oscar Health New York members.
- For organizational/facility providers, Oscar Health enforces firm minimums of $1,000,000/$3,000,000 liability coverage and accreditation or survey currency within the last three years. For small practices, this can be hard to arrange.
Final Word
That’s it! We’ve reached the end of our guide to credentialing with Oscar Health in New York. But before we wrap up this guide, let’s quickly recap some of the important points that we discussed:
- For individual providers, the credentialing process is very simple and requires a fully updated CAQH profile. There is also a second path for providers who don’t have a CAQH profile, and in this case, they have to submit a Practitioner Disclosure Questionnaire.
- Standard turnaround is up to 45 days.
- New York’s 90-day provisional credentialing law applies to Oscar Health, but only protects newly licensed or relocated providers.
- Oscar Health’s New York coverage area is filed county by county.
The insurance credentialing process can be very confusing and frustrating, especially if you are a new provider. That’s why it is better to get professional help. Our team at NeuraBill offers premium insurance credentialing services at affordable rates and with guaranteed results.
