Claim Submission Requirements
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Defines Oscar Health's requirements for complete and valid claims submission, applicable to providers submitting professional and institutional claims for member reimbursement.
No material clinical or coverage changes in this revision.
Claim Acceptance and Required Data Elements
Claim acceptance criteria
Requirements for claim acceptance and necessary data elements and field placement.
Required patient & service elements
- Full patient name
- Patient date of birth
- Member identification number
- Date of service
- Complete service level information (as applicable)
- Place of service codes
- Bill Type
- Discharge Status
- Source of Admission
- Type of Admission
- Condition code
Diagnosis & procedure coding
- Principal or Primary Diagnosis (ICD-10-CM)
- Additional diagnosis codes (ICD-10-CM)
- Procedure codes (CPT and/or ICD-10-PCS)
- Procedure, equipment, drugs, and service codes (HCPCS)
Billing details
- Modifiers (must be present when applicable)
- Revenue codes
- Certain revenue codes must have an associated CPT or HCPCS code as defined by the UB-04 Data Specifications Manual
- Charge information and units
Drug coding
- National Drug Code (NDC)
Provider identification and taxonomy
- Service provider's name and address
- National Provider Identifier (NPI) — must be present and populated in specified loops/fields
- Provider's federal tax identification number (TIN) — must be present and populated in specified loops/fields
- Provider's National Uniform Claim Committee (NUCC) Taxonomy Codes — must be present and populated in specified loops/fields
Required Code Systems
| ICD-10-CM | Diagnosis coding required for principal and additional diagnoses |
| CPT | Procedure coding required for submitted services |
| HCPCS | Procedure, equipment, drugs, and service codes |
| NDC | National Drug Code for drug billing |
| ICD-10-CM | Diagnosis coding required for principal and additional diagnoses |
| CPT | Procedure coding required for submitted services |
| HCPCS | Procedure, equipment, drugs, and service codes |
| NDC | National Drug Code for drug billing |
Authorization, Medical Necessity, and Provider Responsibilities
Authorization and medical necessity requirements
Oscar's reimbursement policies state that coverage alone does not guarantee payment; services must meet authorization and medical necessity guidelines for the procedure, diagnosis, and member's state of residence. Providers are responsible for submission of accurate documentation of services performed and must follow applicable authorization and medical necessity requirements; failure to meet these requirements may result in denial or recoupment of payment.
- Ensure any required prior authorization is obtained per the member’s benefit and state requirements before rendering services.
- Document clinical necessity tied to the procedure and diagnosis in the medical record and include that documentation with claim submission when required.
- Follow applicable coding and billing guidelines; noncompliance may result in denial or recoupment.
Key Definitions for Claim Submission
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.