Gold Card Program

Gold Card is part of HMSA's Utilization Management Program. It uses a stratified approach to intensify, decrease or eliminate precertification or other documentation requirements for selected providers based on their demonstrated compliance with HMSA clinical and administrative requirements.  Review criteria may include HMSA medical policies, MCG Guidelines, nationally recognized clinical criteria, CMS guidelines, and CPT guidelines.

Providers who consistently demonstrate compliance may qualify for reduced administrative requirements, such as exemption from precertification, claim documentation requirements, or periodic utilization management reviews. Providers with ongoing compliance concerns may be subject to intensified precertification or documentation requirements, recoupment of overpayments, or other corrective action.

Provider compliance is determined through data analysis and may be validated through medical record reviews. For example, annual monitoring of utilization data identified bariatric surgery as a potential Gold Card service.  HMSA reviewed the 30 most recent precertification requests and evaluated compliance with clinical and administrative requirements. Surgeons with high case volume and low denial rate were deemed eligible for a precertification waiver for bariatric surgery services. Providers are notified in writing of Gold Card determinations and any medical record review findings.

Gold Card status is generally granted for one year and is reviewed annually for renewal. During the Gold Card period, HMSA may periodically request and review medical records to verify continued compliance. If a review identifies non-compliance with HMSA's clinical or administrative requirements, HMSA may recover payment for the service and rescind the provider's Gold Card eligibility. Providers are given advance notice of any changes to their Gold Card status.

If a Gold Card provider is uncertain as to whether a particular case meets HMSA's Payment Determination Criteria, the provider may request a payment determination review.  Requests submitted under these circumstances will not be considered in the provider’s annual Gold Card renewal evaluation.

Revision History