CurrentUnitedHealthcarePolicy N/A

Michigan Gold Card Prior Authorization Exemptions

Governs prior authorization exemption (Gold Card) eligibility and processes for in-network Michigan providers serving fully insured commercial plan members; describes qualifications, notification, claims handling, and review processes.

Policy Summary

PayerUnitedHealthcare

PolicyMichigan Gold Card Prior Authorization Exemptions

Policy CodePolicy N/A

Change TypeRevised (operational update)

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionDo not submit prior authorizations for services included in the Gold Card program; submit claims normally without a prior authorization number.

SourceLink

POLICY UPDATE CHANGES

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

92%minimum final approval rate per year

10minimum prior auth requests per year

Jul 1, 2022 - Jun 30, 2024evaluation period

Dec. 2024qualification notices sent

Jan. 31, 2025review request deadline

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Gold Card Exemption Criteria

Gold Card exemption criteria and operational rules

Covered without prior authorization when ALL of the following conditions are met:

ALL of the following

Provider is in-network and practices in Michigan
Provider submitted at least 10 prior authorization requests per year for the evaluated service codes during the two-year period (Jul 1, 2022 - Jun 30, 2024)
Provider had a 92% or greater final approval rate for each of the two years evaluated for the included service codes
Service is included in UnitedHealthcare's Gold Card program list (only services on that list are exempt); services not on the list still require prior authorization

Program scope note: Exemptions apply only to fully insured commercial plans in Michigan; other funding types are not covered by this exemption

Operational rule: If a provider qualifies (is exempt), do not submit prior authorization for the exempted services; submit claims normally without a prior authorization number

Operational rule: If an exempted provider requests services from a non-exempt provider, the requesting (exempt) provider must include their name and TIN on the claim; otherwise a prior authorization is required

Operational rule: Non-exempt providers may request a review of non-exempt status via the Provider Portal Chat by Jan. 31, 2025; a reference number will be provided to track the review

Advance notification requirement: Certain services (Kidney, Transplant, Bariatric, and Ventricular device services) still require advance notification to Optum at 888-936-7246 even if other Gold Card criteria are met

Duration: Exemptions remain in place indefinitely provided the provider continues to comply with the medical policy

Included Codes and Thresholds

Gold Card included service codesmixedCovered

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

Approval rate threshold

Approval rate required92% final approval rate per year (92% or greater for each of the two years evaluated)

Evaluation periodDecisions final between July 1, 2022 and June 30, 2024

Consequence if below thresholdProvider must continue to submit prior authorization requests for that service

Minimum volume threshold

Minimum annual volumeAt least 10 prior authorization requests per year for the evaluated service codes

Evaluation windowMeasured per year across the two-year period July 1, 2022 - June 30, 2024

Provider Responsibilities and Billing

Prior Authorization

Gold Card prior authorization exemption behavior

Providers who meet the Gold Card criteria are exempt from prior authorization for the specific services and codes included in UnitedHealthcare's Gold Card program. To qualify, you must be an in-network provider who submitted at least 10 prior authorization requests per year (for each of the two-year evaluation period: July 1, 2022–June 30, 2024) for the included codes and achieved a final approval rate of 92% or greater in each year. Exemptions apply only to the subset of codes identified in the program; services not included in the Gold Card program still require prior authorization. Continue to submit advance notification for Kidney, Transplant, Bariatric and Ventricular device services to Optum at 888-936-7246.

Qualification period: July 1, 2022–June 30, 2024 (two-year window)
Minimum volume: ≥10 prior authorization requests per year for included codes
Minimum approval rate: ≥92% final approvals in each evaluated year
Exemption limited to specific included codes; other services still require prior authorization
Advance notification for Kidney, Transplant, Bariatric, Ventricular device services: Optum 888-936-7246

Key Terms

Fully insured plan

DefinitionFully insured plan: commercial plan members in the individual, small and large group markets with fully insured coverage

Member identificationFully insured members identified on member ID by 'DOI' or via Eligibility and Benefits lookup

ApplicabilityGold Card exemptions apply only to fully insured commercial plans in Michigan (not other funding types)

Gold Card exemption

What it isStatus granted to in‑network providers who meet volume and approval rate thresholds, exempting them from submitting prior authorizations for specified service codes

ScopeExemption applies only to services included in UnitedHealthcare's Gold Card program list; services not on the list still require prior authorization