CurrentUnitedHealthcarePolicy N/A

Michigan Gold Card prior authorization exemptions (Administrative/Operational Policy)

Governs prior authorization exemptions (Gold Card program) for in-network providers serving fully insured commercial members in Michigan; explains qualification, claim submission, and appeals/review processes for exempted services.

Policy Summary

PayerUnitedHealthcare

PolicyMichigan Gold Card prior authorization exemptions

Policy CodePolicy N/A

Change TypeProgram update / qualification criteria added

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionIf a provider submitted ≥10 prior authorizations per year and had a 92%+ final approval rate each year for the evaluation period, they are exempt from submitting prior authorizations for the included codes.

SourceLink

POLICY UPDATE CHANGES

The 2024 requirements have been updated and this document reflects the program as of Jan 1, 2025.

Providers with a 92% or greater final approval rate for each of two evaluated years (and at least 10 PAs submitted per year) are exempt from prior authorization for the subset of codes included in the program.

Providers can request a review of non-exempt status through the Provider Portal chat by Jan. 31, 2025.

92%Minimum final approval rate

10Minimum PA submissions/year

Jul 1, 2022 - Jun 30, 2024Evaluation period

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Qualification notification

Jan. 31, 2025Review request deadline

Gold Card Exemption — Coverage Criteria

Gold Card exemption criteria and operational rules

Exemptions from prior authorization (Gold Card) are available when ALL of the following criteria are met:

Provider is an in-network provider serving fully insured commercial plan members in Michigan (individual, small and large group).

Applies only to providers subject to UnitedHealthcare prior authorization requirements in Michigan.

The provider submitted at least 10 prior authorization requests per year for the codes included in the Gold Card program, for each year of the two-year evaluation period (Jul 1, 2022 - Jun 30, 2024).

Minimum submission volume required for evaluation.

The provider had a final approval rate of 92% or greater for each year of the two-year evaluation period (Jul 1, 2022 - Jun 30, 2024) for the codes included in the Gold Card program.

92% minimum final approval rate per year to qualify for exemption.

The exemption applies only to services/codes that are included in the UnitedHealthcare Gold Card program; services not included in that subset continue to require prior authorization.

Exemption is limited to gold-carded services for fully insured plans.

Included Codes and Qualification Metrics

Gold Card included codesmixed

Subset list of service codes included in the Gold Card program (specific codes not listed in this document).

inv-03: Minimum approval rate

Threshold92% final approval rate per year (provider must have 92% or greater final approval rate for each of the two evaluated years)

Evaluation periodDecisions final between Jul 1, 2022 and Jun 30, 2024

ScopeApproval rate calculated for the subset of service codes included in the Gold Card program

inv-04: Minimum PA submissions

Minimum submissionsAt least 10 prior authorization requests submitted per year for each of the two years evaluated

Evaluation periodJul 1, 2022 – Jun 30, 2024

What Providers Must Do

Billing Rule

Claim information requirement when exempt provider requests services from a non‑exempt provider

You must include the requesting (exempt) provider’s name and TIN on the claim when an exempt provider requests services from a non‑exempt provider. For paper CMS-1500, place this information in fields 17 and 17B. For UB-04, place it in fields 76–79 or another appropriate field. For electronic claims, populate the corresponding loop/segment in the ASC X12N 837. If the requesting provider name/TIN is not included, a prior authorization is required.

CMS-1500: fields 17 and 17B
UB-04: fields 76–79 (or appropriate field)
Electronic: ASC X12N 837 corresponding provider name/TIN fields

Prior Authorization

Behavior when submitting PA for an exempted service

Key Terms

inv-10: Fully insured

DefinitionFully insured: a member covered under a fully insured commercial plan (individual, small and large group) in Michigan

ID card indicatorMember ID card displays letters 'DOI' in the lower left corner to indicate fully insured status

Eligibility lookupEligibility & Benefits on UHCprovider.com shows funding type 'Fully insured'

inv-11: Gold Card status

DefinitionGold Card status: designation for in-network providers who meet volume and approval rate thresholds and are exempt from prior authorization for included codes

Qualification criteriaIn-network provider; ≥10 PAs submitted per year; 92%+ final approval rate each year for the evaluated two-year period

Policy Summary

PayerUnitedHealthcare

PolicyMichigan Gold Card prior authorization exemptions

Policy CodePolicy N/A

Change TypeProgram update / qualification criteria added

Effective DateJan 1, 2025

Next Review DateN/A

SourceLink

On This Page

Submissions must be for the codes included in the Gold Card program to count toward the threshold

Do not submit a prior authorization (PA) for services for which you have an exemption. Attempting to submit a PA for an exempted service will generate a rejection message reminding you that the service is exempt and no PA is required.

Note

Non‑exempt status review process

If you do not meet exemption criteria and believe your non‑exempt status should be reviewed, you may request a review through the UnitedHealthcare Provider Portal Chat. Requests must be submitted by Jan. 31, 2025. You will receive a reference number to track the review. Review times may vary depending on complexity.

Deadline to request review: Jan. 31, 2025
Start review via: UnitedHealthcare Provider Portal Chat
You will receive: reference number to track progress

Billing Rule

Claim submission for exempted services

When you have a Gold Card exemption, submit claims in the usual manner but do not include a prior authorization number for the services that are exempt. Continue to follow normal billing practices for non‑exempt services and for services excluded from the Gold Card program (for example, Kidney, Transplant, Bariatric and Ventricular device services require advance notification to Optum at 888‑936‑7246).

Do not include a PA number on claims for exempted services
Continue to submit advance notification for Kidney, Transplant, Bariatric and Ventricular device services to Optum: 888‑936‑7246

Scope of exemptionExemption applies only to the subset list of service codes identified in the UnitedHealthcare Gold Card program