September 18, 2022

New Texas gold card law streamlines prior authorizations

Beginning Oct. 1, 2022, certain provisions of Texas House Bill 3459, as known as the “Texas gold card bill,” take effect. This new law reduces prior authorization requirements helping patients get the treatment they need when they need it.

This law applies to Texas in-network physicians and providers serving fully insured, commercial business in the individual, small and large group markets.

What this means

Under this law, we analyze approval rates for at least 5 prior authorization requests for a service submitted by you between Jan. 1, 2022, and June 30, 2022. If you have a 90% or greater final approval rate for those requests for a service, you are exempt from requesting prior authorizations for those services.  You can receive exemptions for multiple services.

If your approval rate for a service is below the 90% threshold, you must keep submitting prior authorization requests for that service.

Notification schedule

In late September, you’ll get a notice telling you which services for which you have an exemption or a notice letting you know that you didn’t qualify for an exemption.

Once the program begins, we will not accept prior authorization requests for gold carded services, and we will pay claims without requiring the prior authorization.

Length of exemptions

Exemptions are open-ended if you comply with plan medical policies. We review services every 6 months to check compliance. If the review shows your approval rate would have dropped below 90% for the specific service, we rescind the exemption. After each 6-month review period, new providers and/or new services for existing providers are added or removed based on the results.

Questions?

Please review the Frequently Asked Questions. You can also join us at the gold carding session at the Texas Provider Expo on Oct. 5, 2022.

PCA-1-22-02828-PO-News
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