Gold Carding Program

According to the March 2023 American Medical Association (AMA) physician survey, patients and clinicians are frustrated by the delays in care due to the current utilization management process. The Gold Carding program provides expedited prior authorization for clinicians who demonstrate adherence to appropriate clinical criteria.

The following is the link to access the March 2023 AMA physician survey:

• March 2023 AMA Physician Survey

Across the industry, the current state of utilization review and management is too often a barrier to good health. While prior authorizations are intended to ensure compliance with evidence-based practices, they can be an obstacle to appropriate care, delaying diagnosis and treatment.

The following is a link to a September 2024 Highmark Health Digital Magazine article:

• Simplifying Prior Authorization with Active Gold Carding and Other Innovations
• Gold Carding and the Prior Authorization Process*

Eligibility*

• Practices and individual providers with a minimum submission history of five* cases per gold carded modality are eligible.
• Practices and individual providers must have a 99%* or higher approval rating for the specified gold carded Current Procedural Terminology (CPT) codes and modalities.  
• Plans must be one of the following: Commercial, Affordable Care Act, Medicare Advantage. 
• Pre-notification must be submitted per the details below. Pre-notifications can be submitted using the same process as a normal authorization request via the Availity Essentials provider portal. 

Availity Essentials

*Eligibility criteria can vary in accordance with state mandates. 

Enrollment 

• Highmark automatically enrolls providers, twice annually, when eligibility criteria are met. 
• Highmark sends notification to qualifying providers when auto enrolled in the program. 

Management 

• Once a provider is Gold Carded, Highmark monitors providers’ ordering trends.  
• Highmark conducts random auditing and/or targeted auditing based on utilization variances. 

Providers will follow a simplified pre-notification process once they are Gold Carded:

• Log into the the Availity Essentials provider portal.

Availity Essentials

• Submit the pre-notification following the same process as beginning an authorization request.  
• The following information is required to submit the pre-notification: 
  • Member ID, name, and date of birth 
  • Procedure, ordering provider, place of service, primary diagnosis code 
  • Person submitting the information and phone number  
  • Performing provider if available  
• The system will recognize the provider and CPT code as meeting Gold Carding program criteria. 
  • No clinical information is needed.  
  • Approval is granted immediately without additional review.  
  • A pre-notification must be submitted for claims to pay regardless of Gold Carding program status. 
• For additional questions or to report an issue, please email goldcardinquiries@highmark.com.

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