How the UnitedHealthcare Gold Card program helps modernize prior authorization
Prior authorization serves as an important checkpoint to help enable access to coverage of clinically appropriate services or medications. And UnitedHealthcare is taking steps to modernize and streamline the process.
One step of that journey occurred in 2023 when UnitedHealthcare eliminated nearly 20% of prior authorizations, as part of a comprehensive effort to simplify the health care experience for consumers and providers.
Then, in 2024, UnitedHealthcare launched a first-of-its-kind national Gold Card program, which recognizes provider groups who consistently adhere to evidence-based care guidelines.
Gold Card provider groups are seeing a reduction in their total prior authorization request volume.
Qualifying care provider groups follow a simple notification process for eligible procedure codes rather than the prior authorization process. This advance notification helps confirm eligibility and network status, but it does not require clinical information.
Gold Card status applies across UnitedHealthcare’s Commercial, Individual Exchange, Medicare Advantage and Medicaid plans. Delegated membership is excluded from the program at this time.
The program is continually evaluated to incorporate additional improvements, while communicating enhancements along the way.
How the UnitedHealthcare Gold Card program works
To qualify for the UnitedHealthcare Gold Card program, a provider group must meet the following criteria for each of the past two consecutive years:
- In-network for at least one line of business
- 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
Provider groups can view their UnitedHealthcare Gold Card program status via the UnitedHealthcare Provider Portal. If provider groups haven’t qualified, they can learn more about how they can qualify in the future.
The importance of prior authorization
Prior authorization plays an important role in improving quality and reducing costs, as it can help members access coverage for safe, effective care supported by the most up-to-date clinical guidelines.
- Prior authorization can help providers and members know if the service requested will be covered before the care is delivered.
- When our members seek care, over 99% of the time there is no prior approval needed, or the approval is obtained quickly (within an average of 2 days or less) so care is not delayed.
- Less than 2% of UnitedHealthcare’s members experience a prior authorization denial annually.
- Prior authorization is never required in an emergency setting.
Prior authorization can also help take unnecessary costs out of the system. Estimated waste due to overtreatment and low-value care in the U.S. costs between $76 billion and $101 billion annually.1
The UnitedHealthcare Gold Card program is an important initiative in our continual efforts to modernize the prior authorization process and simplify the health care experience for both consumers and providers.
We also are launching several new initiatives over the next 18 months that will enable real-time, seamless engagement with providers at the point of entry. These initiatives will empower providers with the necessary information to submit prior authorizations and claims accurately the first time, thereby avoiding denials related to benefits, eligibility, coordination of benefits, reimbursement policies, duplicates, and missing authorizations.
For more information on the Gold Card program, including eligibility criteria and a comprehensive list of Gold Card eligible CPT® codes, visit our national Gold Card program information page.
Share
