CurrentUnitedHealthcarePolicy N/A

West Virginia Gold Card Prior Authorization Exemption Process

Governance of UnitedHealthcare's implementation of West Virginia's gold card law for prior authorization exemptions, affecting West Virginia providers who serve fully insured commercial members in individual, small, and large group markets.

Policy Summary

PayerUnitedHealthcare

PolicyWest Virginia Gold Card Prior Authorization Exemption Process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1,2025

Next Review Date

Key ActionSubmit at least 30 prior authorization requests for a given service in a 12‑month period and maintain a 90% final approval rate over 6 consecutive months to qualify for exemption.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jul 1, 2023 - Jun 30, 2024evaluation window

Dec 2024notice date

30minimum requests (12 mo)

90%approval rate required

Coverage Criteria and Limitations

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Claim Fields, Thresholds, and Coding Requirements

Claim fields for identifying exempt requesting providermixed

Form CMS-1500 fields 17 and 17B	Place requesting/exempt provider name and TIN
Form UB-04 fields 76-79	Place requesting/exempt provider name and TIN
837 (ASC X12N) electronic claims	Include corresponding fields for requesting/exempt provider name and TIN

Minimum requests — 30 prior authorization requests in 12 months

Minimum prior authorization requests30 prior authorization requests for the service within a 12‑month evaluation period (July 1–June 30)

Evaluation periodDecisions final between July 1 and June 30 are used to count the 12‑month total

Per‑service requirementThe 30‑request minimum must be met separately for each service to be eligible

Approval rate threshold — 90% final approval rate in 6 consecutive months

Final approval rate required90% final approval rate in a consecutive 6‑month period

Measurement windowApproval rate calculated using prior authorization decisions finalized during the 12‑month evaluation period (July 1–June 30)

Per‑service measurementApproval rate and 6‑month continuity must be met for each specific service to qualify for exemption

Provider Actions, Billing, and Exemption Processes

Note

Gold card exemption qualification

Gold card exemption qualification — to qualify, a provider must have submitted at least 30 prior authorization requests for a given service within the 12‑month evaluation period (decisions finalized between July 1, 2023 and June 30, 2024) and maintain a 90% final approval rate for that service. If your approval rate for a service falls below 90% for 6 consecutive months you must continue submitting prior authorization requests for that service. Continue to submit advance notification for Kidney Transplant, Bariatric, and Ventricular device services to Optum at 888-936-7246.

Submit ≥30 prior authorization requests for the service in the 12‑month window (final decisions dated between 7/1/2023 and 6/30/2024).
Maintain a ≥90% final approval rate for the service (measured across a 6‑month consecutive period).
Exemptions apply per service — you must meet the criterion for each service separately.

Prior Authorization

Request review of non-exempt status

Request a review of a non‑exempt status by Jan 31, 2025. Start the review through the Chat function in the UnitedHealthcare Provider Portal. You will receive a reference number to track the request; review time may vary by complexity.

Deadline to request review: January 31, 2025.
Initiate via Chat in the UnitedHealthcare Provider Portal — a reference number will be provided.

Billing Rule

Claims submission for exempted services

If you qualify for an exemption, do not submit prior authorization requests for the exempted services. Submit claims normally without including a prior authorization number for those exempted services.

Do not submit prior authorization requests for services for which you have been exempted.
When filing claims for exempted services, do not include a prior authorization number — submit claims per standard billing processes.

Documentation Required

Claims requirement when exempt provider details missing

If an exempting provider (the requesting provider) has an exemption but you do not, the exempting provider must be identified on the claim. If the requesting provider's name and TIN are not included on the claim, a prior authorization is required.

Include requesting provider name and TIN on paper CMS‑1500: fields 17 and 17B.
Include requesting provider name and TIN on UB‑04: fields 76‑79 or other appropriate field.
Include the corresponding provider name/TIN fields on electronic ASC X12N 837 claims.
If the requesting provider's name/TIN is missing, prior authorization will be required.

Denial Risk

Prohibition on submitting authorizations when exempt

Do not submit prior authorization requests for services for which you are exempt. Any attempted submission for an exempted service will be rejected with a reminder about the exemption.

Submitting an authorization request for an exempted service triggers an automated rejection reminding you of the exemption.
Do not provide notice or request prior authorization for exempted services under applicable law.

Definitions

Fully insured — definition of fully insured plans

DefinitionFully insured plan: coverage provided to members under fully insured, commercial plans (individual, small and large group markets)

ScopeThe gold card law and exemptions apply only to services for members covered by fully insured commercial plans in West Virginia

Effective date contextUnitedHealthcare implements this for fully insured plans beginning Jan 1, 2025

Gold card exemption definition — exemption from prior authorization when provider meets volume and approval rate criteria

DefinitionGold card exemption: exemption from prior authorization for a specific service when a provider submits at least 30 prior authorization requests for that service in a 12‑month evaluation period and attains a 90% final approval rate in a consecutive 6‑month period

Service‑specificExemption is granted per service; providers may receive exemptions for multiple services if criteria met for each

Continuing complianceExemptions remain while the provider maintains the approval rate and complies with plan medical policies; services not gold‑carded still require prior authorization