By Dr. Steve Kim, Valer Co-Founder and CEO
This is Part 9 of our 10-part series examining the deep, interconnected complexities that keep prior authorization broken. While many hospital and health systems hope new regulation (CMS-0057-F) and AI will improve processes, the real barriers to progress lie in systemic challenges that span technology, workforce, regulation, and operations. These barriers won’t be eliminated by regulation, payer pledges, or today’s AI solutions—but providers have more control than they might think. Throughout the series, we’ll break down the entire prior auth landscape and include practical recommendations that can make a difference.
Gold carding sounds like the promised land: high-performing providers who consistently demonstrate appropriate utilization earn exemption from prior authorization requirements. No more portal submissions. No more status checking. No more documentation hunts. Just provide care and move on.
Except when you look at how gold carding actually works in practice, the administrative burden doesn’t disappear—it just transforms into different, equally time-consuming activities. Providers must track granular metrics across multiple dimensions, maintain detailed record-keeping systems most EHRs don’t support, and often still submit “advanced notifications” that require nearly as much work as traditional prior authorizations.
Texas implemented gold carding legislation years ago, yet providers report limited success and continued frustration with prior authorization burden. The gap between gold carding’s promise and its operational reality reveals why simple policy solutions often fail to address the complex, interconnected challenges that make prior authorization so persistently difficult.
Challenge #1: The Impossible Tracking Requirements
Gold card qualification requires providers to demonstrate high approval rates—typically 90% or higher—for specific services with specific payers over rolling time periods. This seemingly straightforward standard becomes extraordinarily complex when you consider all the variables involved.
Tracking must be specific to:
- Individual providers or provider groups (not organization-wide)
- Specific health plans, payers, and products (e.g. a Health Plan’s PPO vs. HMO vs. Medicare Advantage)
- Specific procedure codes (individual CPT/HCPCS codes, not broad service categories)
- Rolling time periods (typically 6-12 months of recent authorization history)
A single large physician group might need to track gold card status for dozens of physicians across hundreds of payer-product combinations and thousands of procedure codes. The matrix quickly becomes unmanageable without sophisticated tracking systems, which most organizations don’t have.
Most EHRs weren’t designed to capture and report this level of granular authorization outcome data. Organizations must either build custom reporting solutions or rely on manual spreadsheet tracking, an approach that’s prone to errors and can quickly become outdated.
Even when organizations successfully track this information, the quality of the data is hard to guarantee—not least because denials that may come weeks or months after submission, a lag time that makes consistency and accuracy difficult.
The solution: Implement prior authorization platforms that automatically track authorization outcomes with the granularity required for gold card qualification. These systems should automatically maintain visibility into approval rates by provider, payer, service code, and rolling time period, flagging when providers approach or achieve gold card thresholds. Without this systematic tracking, gold card qualification remains more theoretical than practical.
Challenge #2: “Advanced Notification” That Isn’t Actually No Action Required
One related approach that payers have used to theoretically streamline approvals is the replacement of full prior authorization requirements with “advanced notification” requirements instead of submitting a prior authorization. A common example is for screening colonoscopies which should be covered as routine screening. This sounds positive—notification rather than authorization suggests a lighter touch with less administrative burden.
The reality is more complicated. Advanced notification often requires submitting most of the same information as traditional prior authorization: clinical documentation, procedure details, provider information. Staff must still compile documentation and still track submission status. Yes, you won’t need clinical documentation per se for medical necessity review, but it still represents another manual exercise submitting to a payer portal for tracking purposes.
Payers claim they won’t deny services submitted through notification pathway, however, should you request a biopsy along with the screening colonoscopy, some payers may require an authorization (defeating the purpose of doing a screening colonoscopy).
But this promise comes with caveats. Payers may still conduct retrospective review and deny claims for services that don’t meet medical necessity criteria, leaving providers with the same financial risk as traditional prior authorization denials.
From a patient access team perspective, advanced notification may reduce the wait for approval decisions but doesn’t eliminate the work of preparing and submitting information. Staff report that advanced notification workflows feel remarkably similar to prior authorization workflows, just with different labeling.
This creates confusion and process complexity. Staff must track which services require traditional prior authorization, which require advanced notification, which are covered by gold card exemptions, and which require no submission at all for each of their payers or benefit management systems. The cognitive load of managing these different pathways across multiple payers actually increases administrative complexity rather than reducing it.
The solution: Continue to invest in improving your patient access team’s prior authorization workflows, including solutions that easily surface all the historical performance data and KPIs your team needs, because those processes and that data will be equally relevant regardless of your gold card status.
Challenge #3: Gold Carding, by Definition, Excludes Providers Who Need to Reduce their Administrative Burden the Most
By setting qualification thresholds at 90% approval rates or higher, payers ensure that only providers who rarely have services denied qualify for gold card status. These are precisely the providers for whom prior authorization was least burdensome to begin with—they were already getting virtually all authorizations approved quickly.
For providers who struggle with authorization denials and delays—where burden reduction would be most meaningful—gold card status remains perpetually out of reach. The providers who most need relief from prior authorization burden are systematically excluded from gold card programs.
This creates perverse dynamics where gold carding benefits become another source of administrative tracking burden without delivering meaningful authorization relief to most providers. Organizations must invest in tracking systems to monitor gold card qualification, but only a small percentage of providers ultimately qualify.
By requiring detailed tracking of authorization outcomes, payers gain valuable data about provider utilization patterns without having to process authorizations themselves. Providers essentially conduct their own utilization monitoring as a condition of potential gold card qualification—a valuable process, but one that doesn’t solve their workflow or resourcing challenges.
To be fair to payers, there have been health plan efforts around gold-carding and/or removing authorization requirements, where provider incentives have caused an increase in questionable utilization to cause payers to rethink the value of gold-carding. With the mandate from CMS to remove authorizations for more services, this will only continue to strain provider workflows as they need a system to organize and implement payer and service specific rules within their existing EHR workflows.
The solution: Don’t invest disproportionate resources in gold card qualification efforts that may yield minimal actual workflow relief. Focus instead on improving core prior authorization workflow processes that benefit all providers, regardless of gold card status.
The Pattern of Prior Authorization “Reform” That Doesn’t Reform
Gold carding follows a familiar pattern in prior authorization reform: solutions that sound good in theory but fail to address underlying operational realities. In that way, it’s similar to CMS-0057-F requirements that mandate APIs and transparency without addressing fragmented provider workflows or opaque, proprietary medical necessity criteria. The complexity doesn’t disappear—it just moves around.
The common thread is that these reforms focus on process changes at the margins rather than addressing fundamental questions: Why is prior authorization necessary for so many services? Why do payers maintain proprietary criteria rather than transparent standards? Why does administrative burden continue to grow despite decades of reform efforts?
Moving Beyond the Gold Card Mirage
For healthcare organizations evaluating whether to invest resources in pursuing gold card qualification, the question isn’t whether gold carding sounds appealing—it’s whether the actual operational requirements and workflow changes justify the investment.
Healthcare organizations should:
- Calculate the true cost of implementing tracking systems needed for gold card qualification
- Measure how many providers would actually qualify under payer-specific thresholds
- Evaluate whether qualified providers currently experience significant authorization burden
- Assess whether advanced notification requirements actually reduce workflow complexity
- Compare gold card investment to alternative strategies for reducing authorization burden
In many cases, organizations will find that investing in better core prior authorization processes—workflow standardization, automation, performance tracking, staff training—delivers more operational value than pursuing gold card exemptions that benefit only a small subset of high-performing providers.
The goal shouldn’t be earning exemption from a broken system, but building operational capabilities that make the system more manageable for everyone. Technology platforms like Valer that centralize workflows, automate routine tasks, and provide performance visibility create value regardless of gold card status and benefit all providers, not just those who already have high approval rates.
Next up in Part 10: How AI and automation promises collide with the messy reality of fragmented data, inconsistent workflows, and constant payer changes—and what providers actually need to prepare for meaningful technology adoption.
Frequently Asked Questions About Gold Carding for Prior Authorization
What is gold carding for prior authorization?
Gold carding (or “gold card programs”) allows high-performing providers who demonstrate consistently high prior authorization approval rates—typically 90% or higher—to be exempted from prior authorization requirements for specific services. The concept sounds appealing: providers who rarely have services denied shouldn’t need to submit authorizations. However, implementation is complex, requiring detailed tracking by individual provider, specific payer product, specific procedure codes, and rolling time periods. Most EHRs don’t support this level of granular tracking, making gold card qualification difficult to pursue systematically.
Has gold carding been successful in reducing prior authorization burden?
Results have been mixed at best. Texas implemented gold carding legislation several years ago, but providers report limited success and continued frustration with prior authorization burden. The tracking requirements are extraordinarily complex, qualification thresholds exclude many providers who would benefit most from burden reduction, and some “exemptions” are replaced with “advanced notification” requirements that involve a similar workflow. Gold carding tends to benefit providers who already had minimal authorization burden—those with 90%+ approval rates were already getting services approved quickly—while doing little for providers who struggle with denials and delays.
What is “advanced notification” and how is it different from prior authorization?
Advanced notification is a newer requirement that some payers implement when they reduce their prior authorization lists. While payers position this as simpler than prior authorization, providers report it requires submitting most of the same information – procedure codes, provider information, facility information —to a payer. From a workflow perspective, advanced notification often feels remarkably similar to traditional prior authorization, just with different labeling, creating confusion without meaningful burden reduction.
