The program, which will initially be available to more than 160,000 qualifying providers nationwide for select outpatient services, is designed to streamline the prior authorization review process while maintaining appropriate clinical and quality standards.
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The Gold Card Program recognizes providers with a demonstrated track record of following evidence-based clinical guidelines and consistently meeting clinical review requirements. Eligibility is based on objective performance measures, including approval history, documentation quality, compliance with medical policy, and adherence to applicable regulatory requirements. The program is designed to help reduce administrative burden while ensuring that accountability and program integrity remain - all in support of high-quality care for our members. Centene intends to expand the program to other service types and additional providers over time.
The program was developed based on feedback gathered anonymously from providers across 24 states and represents the latest step in Centene's ongoing efforts to simplify the healthcare experience for providers and members.
Key features of the program include:
Gold Card status for qualifying providers, enabling a pre-notification process for eligible services.
Reduced administrative touchpoints for providers with a demonstrated history of ordering evidence-based services with high rates of approval for evidence-based care.
Objective eligibility criteria based on provider performance, including approval history, documentation quality, compliance with medical policy, and applicable regulatory requirements.
Eligible providers will be contacted regarding program requirements, eligibility, and next steps. Program operation may vary based on applicable state and federal requirements. Providers who do not initially qualify will continue to use the standard review process and will have future opportunities to become eligible for the program.