How the UnitedHealthcare Gold Card program helps modernize prior authorization

Prior authorization serves as an important checkpoint to help ensure a service or prescription is a clinically appropriate option. But UnitedHealthcare is taking steps to modernize and streamline the process. 

One step of that journey occurred last year when UnitedHealthcare eliminated nearly 20% of prior authorizations, as part of a comprehensive effort to simplify the health care experience for consumers and providers.

Now, UnitedHealthcare is launching a first-of-its-kind national Gold Card program, which will recognize provider groups who consistently adhere to evidence-based care guidelines. Provider groups can now 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.

Gold Card provider groups will see a reduction in their total prior authorization request volume.

Qualifying care provider groups will follow a simple notification process for eligible procedure codes rather than the prior authorization process. This advance notification will confirm eligibility and network status, but it will not require clinical information.

Gold Card status will apply across UnitedHealthcare’s Commercial, Individual Exchange, Medicare Advantage and Medicaid plans. Delegated membership is excluded from the program at this time.

The program will continue to be evaluated to incorporate additional improvements, while communicating enhancements along the way. 

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 

Prior authorization plays an important role in reducing costs and improving quality, as it can help ensure members are receiving 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.
  
• Prior authorization is required on fewer than 2% of the claims paid at UnitedHealthcare.
• Less than 2% of UnitedHealthcare’s members experience a prior authorization denial annually.

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. is $76 billion to $101 billion annually.¹

The UnitedHealthcare Gold Card program is the next step in continual efforts to modernize the prior authorization process and simplify the health care experience for both consumers and providers.

For more information on the program, including eligibility criteria and a comprehensive list of Gold Card eligible CPT® codes, visit our national Gold Card program information page.