The country’s largest commercial health insurer revealed details about its new program aimed at reducing unnecessary costs.
Starting October 1, 2024, UnitedHealthcare will debut a nationwide Gold Card program designed to reward contracted provider groups that consistently follow evidence-based care guidelines. By simplifying the prior authorization process, the program aims to enhance efficiency and reduce the administrative burden on healthcare providers.
The Gold Card status will apply across all UnitedHealthcare's commercial, individual exchange, Medicare Advantage, and Medicaid plans. The program is expected to significantly decrease the volume of prior authorization requests, thereby streamlining the overall healthcare experience for both providers and patients. View the gold-card-eligible CPT code list here.
Providers will not have to apply for the Gold Card program, however, to qualify, they must meet the following criteria for each of the past two consecutive years:
- In-network for at least one line of business representing UnitedHealthcare commercial, UnitedHealthcare® Medicare Advantage, UnitedHealthcare Individual Exchange and UnitedHealthcare Community plans.
- A minimum annual volume of at least 10 eligible prior authorizations in each of the two consecutive years of the qualification period across Gold Card eligible codes.
- Have a prior authorization approval rate of 92% or more in each of the two years evaluated, after appeals, on the eligible prior authorization volume.
According to UHC, to determine eligibility practices should do the following:
- Sign to the UHC Provider Portal, then, select Prior Authorizations & Notifications.
- Select the Gold Card Status lookup tool from the “Quick links & tools” section on the right side of the page.
- See the current Gold Card status of all Tax Identification Numbers (TIN) associated with your account, then, select your TIN.
Once a TIN has qualified for the Gold Card program, the status covers all providers associated with that TIN. This means, when ordering a Gold Card service, any provider associated with a Gold Card qualified TIN will not require a prior authorization on the Gold Card designated codes. Providers that earn gold-card status are required to complete advance notification for services, but no clinical information will be requested. Check out the National Gold Card program interactive guide for more details.
Practices that do not initially meet the criteria for Gold Card status will have another opportunity for qualification during the subsequent evaluation period starting on October 1, 2025. UnitedHealthcare will conduct annual reviews to reassess clinician eligibility and program participation.
As part of its ongoing efforts to simplify the healthcare experience, UnitedHealthcare eliminated nearly 20% of prior authorizations last year. They also emphasized the importance of prior authorization in ensuring that beneficiaries receive safe and effective care, supported by the latest clinical guidelines. The company claims that prior authorization is required for fewer than 2% of the claims paid by UHC, and fewer than 2% of health plan members experience related denials. By promoting evidence-based care, the Gold Card program aims to eliminate waste due to overtreatment and low-value care.
UHC's Gold Card program underscores the critical role of an effective prior authorization system in ensuring timely and accurate submissions and approvals. Quadax offers prior authorization services to support healthcare providers in navigating these requirements efficiently. Schedule a strategy call with our team to discuss how we can enhance your revenue cycle management and streamline your prior authorization processes.
