Prior Authorization Exemptions

The Gold Carding Program provides a reduction in prior authorization requirements for select covered services when a care provider demonstrates a high approval rate for prior authorization requests and consistently adheres to evidence based clinical guidelines for those services. The program is designed to reduce administrative burden and improve access to timely, equitable, and high quality care across Georgia.

The program was developed to align with Georgia legislative and regulatory efforts, including House Bill 197 and Senate Bill 5, to modernize prior authorization, improve transparency, and reduce unnecessary administrative steps for high‑performing care providers statewide.

Participants in the Gold Carding Program may:

• Bypass the traditional prior authorization process for designated services.
• Receive automated authorization decisions in real time, when eligibility criteria are met, via Availity Essentials.
• Reduce administrative delays.
• Speed up the time it takes members to receive care.

A participating care provider licensed in the State of Georgia and contracted with Anthem may be eligible to participate in the Gold Carding Program.

Yes. The Gold Carding Program is limited to participating care providers.

Eligibility is determined by a care provider’s prior authorization approval rates for specific services and adherence to established criteria. Eligibility is evaluated at the individual NPI level and not at the practice group or organization level.

To be accepted into the Gold Carding Program for a specific CPT^® code, a participating care provider must have submitted a minimum number of prior authorization requests (currently 10) for that code in the past 12 months and achieved a high approval rate (currently 95%). This analysis is conducted on a CPT‑code‑by‑CPT‑code basis.

No. The program applies only to the following plans:

• Georgia fully insured Health Benefit plans
• State Health Benefit Plan (SHBP)
• University System of Georgia (USG) group plan

It does not apply to other self‑funded or out‑of‑state plans, which are generally not subject to state prior authorization requirements.

Eligible members must be actively enrolled in an eligible health benefit plan in Georgia. You can confirm the funding type in Availity Essentials using the Eligibility and Benefits inquiry. If the information is unclear, Provider Services can assist with verification.

No. Qualification is based solely on individual care provider performance, not on group‑level results.

No. Exemptions apply only to the specific CPT codes listed in the care provider’s eligibility notification.

You will need to notify us via Availity Essentials of a health benefit service for which you are gold carded for an eligible member. You must provide the minimum required data, including your National Provider Identifier (NPI), the member’s demographics, and service codes.

You will not need to provide the clinical information typically required for that service under Anthem’s prior authorization guidelines.

 Once you enter the required information, Availity will automatically validate your credentials and confirm both the member's eligibility and the service's eligibility for the Gold Carding Program. Upon validation, the Availity Essentials platform generates an authorization decision in real time, including an authorization number, and generates an authorization letter you can print or download.

If the member and/or service are not eligible for the Gold Carding Program, Availity will request that you provide all clinical information necessary to evaluate the request against our applicable prior authorization requirements.

Only basic fields are required:

• Care provider NPI
• Member information
• Date of service, service type, and procedure code

No clinical documentation or medical review is required for exempt services.

Availity issues an authorization  after confirming that the requesting care provider is enrolled in the Gold Carding Program for the requested CPT code and that the member has an eligible, active Georgia health benefit plan.

An authorization letter with an authorization number for that service is immediately available for download.

No. The Gold Carding Program is available only through Availity Essentials. If you submit a prior authorization request by phone, email, or fax, Anthem will evaluate it against applicable prior authorization requirements.

• Anthem does not permit a gold carded care provider to request prior authorizations for healthcare services that will be performed by another care provider.
• Exception: Anthem may allow a gold carded care 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 the gold-carded care provider’s behalf using clinical information provided by the gold-carded care provider. In such cases, the Radiology Center serves only a clerical function and will not be eligible to participate in the Gold Carding Program based on any prior authorization requests submitted on behalf of a gold-carded care provider. To the extent that Anthem can identify and attribute that a prior authorization request submitted by a Radiology Center was based on information from the gold-carded care provider, Anthem will consider those requests as part of that gold-carded care provider’s eligibility for ongoing participation in the Gold Carding Program. However, if Anthem is unable to distinguish such data, a gold carded care provider must choose between the efficiency of having a Radiology Center submit prior authorizations on their behalf and the need for sufficient prior authorization requests for specific CPT codes to continue participation in the Gold Carding Program.

Eligibility is based on the following factors:

• Participation in the Member’s Network.
• ≥ 95% 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.

Determinations occur at the individual NPI level and not at the practice or organization levels.

Performance is assessed from July 1 of the previous year, through June 30, of the current year.

Notifications will be issued no later than August and will include details on exempt services and instructions for using Availity Essentials.

Care providers can find the services for which they have been accepted in Availity Essentials. If, after reviewing the Gold Card Eligibility Status, care providers still have questions about their determination, they may submit a Gold Card Provider Inquiry Form to request additional information regarding their eligibility.

The process includes:

• Acknowledgment within seven business days.
• Review of NPI‑level performance data.
• A written response within 30 calendar days.

Status is reviewed annually.

Yes. Status may be rescinded if a care provider:

• Ceases to be a participating provider with any Gold Card eligible network.
• Falls below the 95% approval threshold for a specific CPT code.
• Does not meet the minimum volume requirement of 10 Prior Authorization requests per CPT code during the evaluation period.
• Demonstrates utilization patterns that materially deviate from peer benchmarks or established clinical guidelines, as determined by Anthem.
• Is associated with an open or confirmed case of potential fraud, waste, or abuse.

Care providers will be notified of the annual review decision by the end of August each year.

In the event mid-year changes are necessary, providers will be notified as soon as practicable.

Care providers will be able to view:

• Current prior authorization requirements and criteria.
• Utilization Management (UM) vendor criteria.

Provider Services can be contacted by using the contact information on the member’s ID card to help with:

• Prior authorization processes
• Claim status questions
• Eligibility and benefits
• Availity Essentials navigation