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Wyoming Gold Card prior authorization waivers for behavioral health services

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This document governs Wyoming-specific Gold Card prior authorization exemptions for certain behavioral health services provided to eligible fully insured commercial and Individual Exchange plan members, applying to NPI-specific in-network providers; it does not apply to Medicare Advantage or Medicaid members.

Policy Summary

PayerOptum

PolicyWyoming Gold Card prior authorization waivers for behavioral health services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionInclude the provider NPI on claims for exempt services to avoid denial for lack of prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-01-01effective date of Wyoming Gold Card waivers

5minimum prior auths in evaluation period

90%+minimum approval rate

12 moeligibility review cadence

Gold Card Coverage and Eligibility

Gold Card coverage and operational criteria

Covered when ALL of the following are met:

Provider is in-network and participates in a fully insured Commercial or Individual Exchange plan (NPI-specific).

Provider submitted at least 5 eligible prior authorization requests during the evaluation period (Jan. 1, 2024 - Dec. 31, 2024).

Provider achieved an authorization approval rate of 90% or greater for those eligible prior authorizations during the evaluation period.

Waiver applies only to services and accounts that are in-plan and in-network and is NPI-specific; exemptions apply for new dates of service on or after the exemption effective date.

Gold Card waivers do not apply to members covered by Medicare Advantage or Medicaid plans (exclusion).

Exempted Codes and Evaluation Metrics

Exempted procedure and revenue codesmixedCovered

Select procedure and revenue codes exempted for qualifying NPIs (specific codes provided in provider notification)

inv-03: Minimum prior authorization submissions — 5 eligible prior authorizations in evaluation period

Minimum prior authorization submissionsProvider must have submitted at least 5 eligible prior authorizations during the evaluation period.

Applies toEligible submissions are those for in-network services for fully insured Commercial or Individual Exchange plan members.

ExclusionsDoes not apply to Medicare Advantage or Medicaid members — those providers must follow existing PA requirements.

inv-04: Minimum approval rate — 90% authorization approval rate during evaluation period

Minimum approval rateProvider must have a 90% or greater authorization approval rate during the evaluation period.

Evaluation windowApproval rate is measured over the designated 12-month evaluation period (see evaluation period block).

VerificationOptum Behavioral Health reviews approval rates as part of program eligibility and will notify providers of changes.

inv-05: Evaluation period dates — Jan. 1, 2024 - Dec. 31, 2024 (example evaluation period)

Evaluation period datesJan. 1, 2024 - Dec. 31, 2024 (12-month evaluation period).

Review cadenceOptum reviews Gold Card eligibility on a 12-month cycle and may change timing or criteria with advance notice.

ContextEligibility criteria (minimum submissions and approval rate) are measured within this example evaluation period.

Provider Responsibilities and Billing Rules

Prior Authorization

Gold Card exemption effect

NPI-specific prior authorization exemptions apply for listed services; providers with exemptions do not need to submit prior authorization requests for the exempt NPI and select procedure and revenue codes for new dates of service on or after the exemption effective date.

Denial Risk

Include NPI on claims for exempt services

When submitting claims for exempt services, include the provider NPI on the claim; failure to include the NPI will result in claims being denied due to lack of prior authorization.

Documentation Required

Optional advance notification to validate coverage

Providers may optionally complete an advance notification (online via Provider Express or by phone) to validate coverage, check member eligibility and network status, and receive a notification number to reference on claims.

Online: use ProviderExpress (Auths > Auth Request) with your One Healthcare ID.
By phone: call the number on the back of the member ID card when portal entry is not available.
If case is Gold-Card eligible you will receive a notification number to use on claims.

Prior Authorization

Continue prior authorization when no exemption granted

If a provider does not qualify for a Wyoming Gold Card exemption, they must continue to submit prior authorization requests for all services that require approval before services are rendered per plan requirements.

Key Terms and Scope

inv-10: Fully insured plan — Fully insured plan identification

DefinitionFully insured plan: a plan identified by the member ID card displaying 'DOI' in the lower left corner.

ScopeWyoming Gold Card waivers apply only to eligible fully insured Commercial and Individual Exchange plan members.

In-network requirementWaivers apply to accounts that are in plan and in-network for the identified services.

inv-11: Gold Card waiver / exemption — NPI-specific exemption applying to in-network providers for eligible services

DefinitionGold Card waiver / exemption: an NPI-specific prior authorization exemption granted to qualifying in‑network providers for listed services and codes starting on the exemption effective date.

NotificationQualifying providers are notified by email and receive a list of exempt services and the exemption effective date.

Claims requirementWhen submitting claims for exempt services, include the exempt NPI to avoid denial for lack of prior authorization.

Policy Summary

PayerOptum

PolicyWyoming Gold Card prior authorization waivers for behavioral health services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionInclude the provider NPI on claims for exempt services to avoid denial for lack of prior authorization.

SourceLink

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