Gold Carding and Prior Authorization: How It Works and Why It Matters

Gold carding is a program that allows certain providers to bypass the traditional prior authorization process, which typically requires clinicians to obtain payer approval before specific services are performed.

Providers earn gold card status by consistently following payer guidelines and demonstrating appropriate use of medical services. Once approved, they can order defined tests or procedures without waiting for utilization management review, allowing faster care delivery and reducing administrative burden for clinical staff.

How Gold Carding Works

Payers review a provider’s performance over time. Typically, the prior authorization (PA) process requires clinicians to submit documentation, wait for payer review, and obtain approval before certain tests or procedures can be performed. Gold carding allows providers to bypass many of these steps. Once approved, providers can submit a simple advance notification rather than full documentation, enabling faster approvals and less administrative work.

Program Eligibility and Application

Eligibility for gold card programs varies by payer. Providers generally earn status by demonstrating consistent adherence to clinical guidelines and high approval rates over time. Some programs, like UnitedHealthcare’s, require providers to submit an application or notification to confirm eligibility, while others may automatically enroll qualifying clinicians and notify them via email.

It’s important to check with individual payers for specific requirements and instructions to start the gold carding process. Get UnitedHealthcare’s program details or more information about UHC gold card qualification criteria through the American Academy of Family Physicians.

Why Health Plans Use Gold Carding

Health plans implement gold carding for several strategic and operational reasons. Policy‑focused groups such as the National Conference of Insurance Legislators (NCOIL) describe gold carding as a mechanism to exempt providers with a strong record of adherence to prior authorization criteria from ongoing submission requirements. This promotes more timely access to care and concentrates utilization management resources on outlier cases.  

Typical Prior Authorization Workflow

Before gold carding exists, providers must go through a multi‑step prior authorization process for services subject to utilization management:

1. Submit a detailed authorization request with clinical documentation.
2. Wait for payer review and determination, which can take days or longer depending on the service and plan.
3. Respond to questions or provide additional information if requested.
4. Receive an approval or denial. If denied, providers may appeal or revise the documentation.

This workflow contributes to well‑documented administrative burden: physicians and staff spend an average of 14 hours per week managing PA requests, including submissions and appeals.  

Because of this process, payers also generate large volumes of work. For example, Medicare Advantage insurers made nearly 50 million PA determinations in 2023, with about 6.4% denied and only a small share of denials appealed.  

How Gold Carding Changes the Workflow

Gold carding alters this workflow for providers who meet specific performance criteria:

• Instead of submitting full clinical documentation for every request, qualified providers submit only a simple notification of the intended service.
• The payer then automatically approves the request for defined codes or procedures without the typical review steps.
• This eliminates much of the waiting, phone calls, faxing, and follow‑ups that characterize standard PA workflows.

In practice, some programs report up to an 85–90% reduction in administrative processing time for gold‑carded services, meaning less time spent by clinicians and staff on paperwork and more predictable scheduling for patients.

Why Plans Adopt Gold Carding

Health plans use gold carding to:

• Reduce administrative pressure on both payers and high‑performing providers
• Shorten patient wait times for care by cutting out waiting periods inherent to full prior authorization reviews
• Allocate utilization management resources more efficiently toward providers with less consistent PA compliance (NCOIL)

Some surveys indicate that nearly six in 10 plans had implemented gold carding for medical services by 2022, showing growing adoption over time.  

PA Approvals, Denials, and Burden: Context for Gold Carding’s Value

• Denial Rates: In Medicare Advantage in 2023, about 6.4% of PA requests were denied, meaning millions of requests result in delays or additional administrative steps.  
• Appeals Burden: Only a small portion of those denials are appealed, even though most appeals are ultimately overturned, adding further delay and work for providers.  
• Staff Time: Practices often spend the equivalent of two full working days per week on PA tasks.  
• Patient Impact: Most clinicians report that PA requirements delay necessary care.  

In contrast, gold carding can eliminate these repetitive submission and review steps for qualifying services, which can reduce burden and speed care delivery, all of which are core goals of utilization management reform.

Services Commonly Included in Gold Carding

Gold card programs often begin with high-volume, highly standardized services where prior authorization decisions are predictable. While diagnostic imaging is a common starting point, gold carding frequently extends to other services that generate significant administrative workload and frequent authorization requests.

Common service categories included in gold card programs may include:

• Diagnostic imaging, such as CT and MRI studies with well-established clinical criteria
• Outpatient procedures, including certain endoscopic, musculoskeletal, or interventional services
• Laboratory and genetic testing that follows defined medical necessity guidelines
• Durable medical equipment (DME) and supplies that are routinely approved for specific conditions

Clinicians tend to save the most time when gold carding applies to services they order frequently and for which approvals are rarely denied. By removing repetitive documentation and review for these routine requests, gold carding reduces staff workload, shortens scheduling delays, and allows providers to focus attention on more complex cases that genuinely require clinical review.

More information on these codes is described in UnitedHealthcare’s Gold Card FAQ.

Services Commonly Excluded from Gold Carding

While gold carding programs reduce prior authorization requirements for many high-volume and predictable services, they do not apply universally. Certain services remain excluded due to higher cost, greater clinical variability, or increased risk of inappropriate utilization.

Genetic testing is a common exclusion because test selection and interpretation often require detailed clinical justification, and costs can vary widely depending on the assay and clinical indication. As a result, most payers continue to require traditional prior authorization for genetic testing even when a provider holds gold card status for other services.

Other services may also fall outside gold carding programs, including advanced procedures and elective interventions where clinical decision-making is more nuanced or where utilization patterns vary significantly between patients. In these cases, payers typically maintain full prior authorization requirements to ensure appropriate use.

Gold carding may also be limited by care setting or service scope. For example, exemptions may apply only to outpatient services or to specific procedure codes, while inpatient care or newer technologies remain subject to standard authorization processes.

Technology Support When Gold Carding Is Not an Option

Many services fall outside of gold carding programs, requiring providers to continue using traditional prior authorization workflows. In these cases, providers increasingly rely on technology platforms that streamline and automate the PA process.

careviso’s seeQer platform speeds up prior authorization by making payer-specific rules visible at the point of order. This helps staff quickly determine whether authorization is required and what information must be submitted. The platform pulls relevant clinical and administrative data from existing systems and pre-populates payer forms to reduce manual entry and rework.

seeQer also helps prevent delays by validating requests against payer requirements before submission and by providing real-time visibility into authorization status. These capabilities reduce administrative effort, improve submission accuracy, and help teams move requests through the PA process more efficiently.

READ MORE: How careviso supports prior authorization and workflow transparency

The Future of Gold Carding Prior Authorization

Today, gold carding programs are typically managed through ongoing performance monitoring rather than one-time approvals. Payers govern these programs by reviewing provider ordering behavior and overall adherence to clinical guidelines over time.

Gold card status may be audited periodically and adjusted as utilization trends shift or as payer policies and regulatory requirements change. This approach allows health plans to refine eligibility while maintaining appropriate oversight within their utilization management strategies.

As these programs continue to evolve, providers who consistently follow evidence-based guidelines are well positioned to qualify for gold card status when opportunities arise. For providers who are not eligible, or for services that remain outside gold card programs, technology platforms like careviso’s seeQer platform offer a practical alternative.

By streamlining prior authorization workflows and reducing administrative effort, seeQer helps providers achieve meaningful time savings and move care forward more efficiently, regardless of gold card participation.