Surprise Bills (out-of-network provider charges)
Governs when a member may submit a surprise bill for services from non‑participating providers and describes submission instructions and Oscar Health's payment methodology. Affects members who received services from out‑of‑network providers without prior knowledge or proper consent and providers submitting claims.
No material clinical or coverage changes in this revision.
Surprise Bill Qualification & Payment
Surprise bill qualification and payment
Covered when ALL of the following apply:
ALL of the following
ONE of
- Member received services from a non‑participating physician at a participating hospital or ambulatory surgical center when a participating physician was not available, or a non‑participating physician provided services without the member's knowledge, or unforeseen medical circumstances arose at the time services were provided. The member did not choose to receive services from a non‑participating physician instead of an available participating physician.
- Member was referred by a participating physician to a non‑participating provider and did not sign written consent acknowledging that the services would be out‑of‑network and could result in costs not covered by Oscar. (A referral to a non‑participating provider includes when, during a visit with a participating physician, a non‑participating provider treats the member, or when a participating physician takes a specimen in the office and sends it to a non‑participating laboratory or pathologist.)
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.