CurrentCignaPolicy N/A

Vermont Gold Carding Pilot Program

Defines a Cigna pilot that exempts eligible Vermont providers from prior authorization/precertification for specific procedures when they meet high-approval performance criteria; affects contracted providers in Vermont performing services that normally require prior auth.

Policy Summary

PayerCigna

PolicyVermont Gold Carding Pilot Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMarch 2022

Next Review DateN/A

Key ActionIf a provider averages 30 procedures/year and has 100% prior authorization approvals over six months, Cigna will exempt that procedure from prior authorization for the next six months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%approval rate required over six months to qualify

6 monthsmeasurement period

30/yrminimum avg annual frequency

quarterlyevaluation frequency

Gold Carding Eligibility & Maintenance

Gold Card eligibility and maintenance criteria

Covered when ALL of the following are met:

Criteria set for exemption (Gold Card):

ALL of the following

Provider is contracted with Cigna and performs services that require prior authorization or precertification.
Behavioral providers performing TMS or ABA are included.
Provider performs the procedure an average of 30 times per year.
Provider has 100% approvals of prior authorization or precertification requests for that procedure over a six-month period.

ALL of the following

Policy Summary

PayerCigna

PolicyVermont Gold Carding Pilot Program

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMarch 2022

Next Review DateN/A

Key ActionIf a provider averages 30 procedures/year and has 100% prior authorization approvals over six months, Cigna will exempt that procedure from prior authorization for the next six months.

SourceLink

On This Page

If the above requirements are met, Cigna will not require prior authorization or precertification for that procedure for the next six months.
Exemption is reviewed prior to renewal at the end of the six‑month period.
Exemption is subject to internal audit by Cigna at any time and may be rescinded if Cigna determines the provider is not performing the procedure in keeping with coverage criteria and applicable benefit plan language.
Cigna will notify providers when they become eligible and will perform quarterly evaluations to add or remove participants.

Provider Notification, Audit, and Exemption Operations

Prior Authorization

Gold Carding exemption and audit

If a provider performs a procedure an average of 30 times per year and, over a six‑month period, has received approvals on 100% of prior authorization or precertification requests for that procedure, Cigna will waive the prior authorization/precertification requirement for that procedure for the following six months. The exemption is subject to Cigna internal audit at any time and may be rescinded if Cigna determines the provider is not performing the procedure in accordance with Cigna coverage criteria and the applicable benefit plan language. At the end of the six‑month exemption period, the exemption will be reviewed prior to any renewal.

Condition for exemption: average of 30 procedures per year
Performance threshold: 100% approval rate on prior authorization/precertification requests over a six‑month period
Exemption duration: six months (subject to review before renewal)
Audit/monitoring: exemption subject to internal Cigna audit and may be rescinded if performance is inconsistent with coverage criteria or benefit plan language

Note

Eligibility notification and evaluations

Any provider contracted with Cigna who performs services that require prior authorization or precertification is eligible to participate in the program. For behavioral services, providers who perform transcranial magnetic stimulation or applied behavior analysis are eligible. Cigna will notify providers when they become eligible for the pilot program and will perform quarterly evaluations to add or remove eligible provider participants.

Eligible participants: any Cigna‑contracted provider who performs services requiring prior authorization/precertification
Behavioral services: includes transcranial magnetic stimulation and applied behavior analysis providers
Notification: Cigna will notify providers when they become eligible
Monitoring cadence: quarterly evaluations to add or remove participants

Key Terms

inv-06: Vermont Gold Carding Pilot Program

Program nameVermont Gold Carding Pilot Program

AuthorityEstablished under Vermont House Bill 960 to implement a pilot exempting or streamlining certain prior authorization/precertification requirements

ScopeApplies to a subset of participating health care providers contracted with Cigna in Vermont who perform services that require prior authorization or precertification

inv-07: Temporary waiver of prior authorization/precertification

Definition (exemption)Temporary waiver of prior authorization/precertification requirements for a specific procedure for six months following qualification

Qualification reviewExemption is reviewed prior to renewal at the end of the six-month period

Audit and rescissionExemption is subject to internal audit by Cigna at any time and may be rescinded if provider is not performing the procedure consistent with coverage criteria and benefit plan language

OpenPayer

Vermont Gold Carding Pilot Program

Gold Carding Eligibility & Maintenance

Coding and Measurement Thresholds

Provider Notification, Audit, and Exemption Operations

Key Terms