Prior Authorization Exemptions
Under 2024 Colorado House Bill 1149, care providers might be exempt from submitting prior authorization requests for certain healthcare services if they met the eligibility requirements to participate in the Colorado Gold Carding Program offered by HMO Colorado, Inc. and Rocky Mountain Hospital and Medical Services, Inc. (collectively, "Anthem").
Attention, care providers
We will start reviewing care providers for those participating in the Colorado Gold Carding Program set to take effect around July 1, 2026. In accordance with 2024 Colorado House Bill 1149, Anthem will automatically consider for eligibility to participate in the Colorado Gold Carding Program any care provider who is:
- Duly licensed by the State of Colorado.
- In good standing with their licensing board.
- Credentialed with Anthem.
- Contracted with Anthem to furnish services or prescribe prescription drugs to members enrolled in fully-insured health benefit plans issued and delivered in Colorado.
- In good standing with Anthem, which means:
- A care provider who is a collaborative partner with Anthem, which means the provider:
- Is professional in communications.
- Participates in cost of care and value-based programs, as applicable.
- Is not currently subject to a Special Investigative Unit (SIU) investigation.
- Has not been involved in an SIU investigation where adverse findings were made in the past two years.
- Has not been the subject of any founded regulatory complaints (for example, Department of Insurance, Centers for Medicare & Medicaid Services) in the past two years.
- A care provider who is a collaborative partner with Anthem, which means the provider:
If you are deemed eligible to participate in the Colorado Gold Carding Program, you will receive a letter in Availity Essentials welcoming you to the Colorado Gold Carding Program along with key information for your participation in the program.
Frequently Asked Questions
General Program Information
What is the Colorado Gold Carding Program?
HMO Colorado, Inc. and Rocky Mountain Hospital and Medical Services, Inc. (collectively, "Anthem") adopted a Gold Carding Program that provides automatic authorization for designated services when a provider demonstrates a high approval rate for prior authorization requests and consistent adherence to evidence-based clinical guidelines for specific services. The program is designed to reduce administrative burden and improve access to timely, equitable, and high-quality care across Colorado.
Why was this program created?
The program was developed to meet the requirements of Colorado House Bill 24-1149, which aims to modernize prior authorization, improve transparency, and reduce unnecessary administrative steps for high-performing providers across Colorado.
How does this Gold Carding Program benefit me as a provider?
Participants in the Gold Carding Program may:
- Avoid the traditional prior authorization process for designated services.
- Receive instant automated approval through the Availity Essentials website.
Scope and Eligibility
Am I, as a care provider, eligible to participate in Anthem’s Gold Carding Program?
A participating care provider licensed in Colorado and contracted with Anthem may be eligible to participate in the Anthem Gold Carding Program.
Determinations are based on a care provider's approval rates for prior authorization on specific services and adherence to established criteria.
Eligibility is evaluated at the individual NPI level — not the practice group or organization.
A participating care provider must have submitted 10 prior authorization requests for a specific CPT® code in the last 12 months with a 90% approval rate to be accepted into the Gold Carding Program for that specific CPT code. This analysis is done on a code-by-code basis.
Are all my Anthem patients eligible to participate in this program?
No. The program applies only to Anthem members with fully insured health benefit plans issued and delivered in Colorado. It does not apply to Anthem members with the following health benefit plans:
- Self-funded / Administrative Services Only (ASO) plans
- Employee Retirement Income Security Act (ERISA) governed plans
- Fully insured plans issued and delivered outside Colorado
How can I confirm whether my patient has fully insured health benefit plan issued and delivered in Colorado?
You can confirm your patient’s funding type in Availity Essentials using the Eligibility & Benefits inquiry. If the information is unclear, Provider Services can assist with verification.
If my colleague qualifies, do I automatically qualify too?
No. Qualification is based solely on individual provider performance, not a group’s or organization’s performance.
If I qualify for Anthem's Gold Carding Program, will all services be exempt from prior authorization?
No. Exemptions apply only to the specific CPT codes identified in your eligibility letter that welcomes you to the Gold Carding Program.
How the Program Works
Once I am accepted into the Gold Carding Program, what changes in my workflow?
You will have to notify Anthem via Availity Essentials that you will be furnishing a health benefit service for which you are gold carded to a member with a Colorado fully-insured health benefit plan. You must provide minimum data such as your NPI, the member’s demographics, and service codes.
You will not need to provide the clinical information required for that service under Anthem’s prior authorization guidelines.
Once you enter the required information, Availity Essentials will automatically validate that you, your member, and the service are eligible for the Gold Carding Program. Upon validation, the Availity Essentials system instantly issues an authorization approval for the requested service with an authorization number and generates an authorization letter you can print or download.
If the member and/or service is/are not eligible for the Gold Carding Program, then Availity Essentials will request you supply all clinical information necessary to evaluate the request under Anthem's applicable prior authorization requirements.
What information will I need to enter in Availity Essentials?
Only basic fields are required:
- Provider name and NPI
- Member name, identification number, date of birth, and relationship to subscriber
- Date of service, service type, and procedure code (CPT)
No clinical documentation or medical review is required for exempt services.
If the member and/or service is/are not eligible for the Gold Carding Program, then Availity Essentials will request you supply all clinical information necessary to evaluate the request under Anthem's applicable prior authorization requirements.
How quickly will I receive authorization?
Availity Essentials instantly issues an authorization once the system confirms the requesting provider is in the Gold Card Program for the specific CPT code being requested and the member has an active fully-insured health benefit plan issued and delivered in Colorado.
An authorization letter is immediately available to download with an authorization number for that service.
If the member and/or service is/are not eligible for the Gold Carding Program, then Availity Essentials will request you supply all clinical information necessary to evaluate the request under Anthem's applicable prior authorization requirements.
Can I submit a prior authorization over the phone, via email, or via fax as part of the Gold Card Program?
No. The Gold Carding Program is only available through Availity Essentials. If you submit a prior authorization request via phone, email, or fax, Anthem will evaluate the request against applicable prior authorization requirements.
To be clear, the Gold Carding Program is not available via phone, email or fax.
What if I order the service, but another provider or facility performs it?
- Anthem does not permit a Gold Carded care provider to request prior authorizations for healthcare services that will be performed by another care provider or prescription drugs that will be professionally administered by (or ordered by) another care provider.
- If you engage in such conduct, Anthem reserves the right to remove you from the Gold Carding Program.
- Exception: The only exception is that Anthem will permit a Gold Carded Provider to: (i) determine that a member requires radiology imaging and (ii) request that a third-party radiology organization ("Radiology Center") submit the prior authorization on behalf of the Gold Carded Provider using clinical information provided by the Gold Carded Provider. In such cases, Radiology Center performs only a clerical function and will not be eligible to participate in the Gold Carding Program based on any prior authorization requests submitted on a Gold Carded Provider's behalf.
- To the extent that Anthem can ascertain that a prior authorization request submitted by a Radiology Center was based on information from the Gold Carded Provider, then Anthem will consider those requests as part of that Gold Carded Provider’s eligibility to continue in the Gold Carding Program. However, if Anthem is unable to distinguish such data, then a Gold Carding Provider must choose between the efficiency of a Radiology Center submitting prior authorizations on their behalf versus having sufficient prior authorization requests for specific CPT codes to continue in the Gold Carding Program.
Performance Evaluation
How will my eligibility be determined?
Eligibility is based on factors such as:
- ≥90% approval rate for the evaluated services
- At least 10 prior authorization requests per service (CPT® code) during the review period
- Demonstrated adherence to evidence-based guidelines
- Appropriate and efficient utilization patterns
- No suspected engagement in fraud, waste, or abuse
- Violates the Gold Carding Program rules
Determinations occur on an individual National Provider ID (NPI) level. Determinations do NOT occur at the practice and organization level.
When is the evaluation period?
Performance is assessed from April 1, 2025 – March 31, 2026.
When will I be notified if I qualify?
Notifications will be issued no later than September 1, 2026, including details on exempt services and instructions for using Availity.
If I Disagree with My Eligibility Determination
What can I do if I believe my eligibility was evaluated incorrectly?
Providers may submit a Gold Card Provider Eligibility Review Inquiry Form to request an informal review of their data and eligibility status.
What will happen after I submit an inquiry?
The process includes:
- Acknowledgment within 7 business days.
- Review of NPI-level performance data.
- A written determination within 30 calendar days.
Does this informal review replace a clinical appeal?
No. The informal review process only applies to Gold Card Program eligibility determinations. Clinical appeals must follow the standard appeals process outlined in the Anthem Colorado Provider Manual.
If I still disagree, can I request arbitration?
Yes. Arbitration is available as outlined in the Anthem Colorado Provider Manual.
Ongoing Participation and Annual Review
How often is my Gold Card status reviewed?
Status is reviewed annually.
Can my Gold Card status be revoked?
Yes. Status may be rescinded if a care provider:
- Falls below the 90% approval threshold for a specific CPT code.
- Does not meet minimum volume requirements of 10 PA requests per CPT code during the evaluation period.
- Demonstrates a greater than 10% year-over-year variance in utilization.
- Is associated with open or confirmed case about potential fraud, waste, or abuse behavior.
When will I be notified of changes?
Care providers will be notified within 30 days of the annual review decision.
When do changes take effect?
Any change — continued exemption, new exemption, or rescission — takes effect July 1 each year.
Reporting and Website Information
What information will be available on the public website?
Care providers will be able to view:
- Current prior authorization requirements and criteria.
- The number of care providers in the Gold Carding Program, including specialty areas.
- The services (by CPT codes) eligible for the Gold Carding Program.
Anthem will share website details once the data is collected and validated.
Support and Contacts
Who can I contact for general prior authorization questions?
Provider Services can be contacted by using the number on the member's ID card to help with:
- Prior Authorization processes.
- Claim status questions.
- Eligibility and benefits.
- Availity Essentials website navigation.
How can I submit an eligibility inquiry?
Care providers may complete the Gold Card Provider Eligibility Review Inquiry Form and submit it with supporting documentation to the designated program email. Acknowledgment and review follow the standard informal review process.
Interested in becoming a provider in the Anthem network?
We look forward to working with you to provide quality service for our members.