A Denver orthopedic practice manager forwarded us a letter from Aetna last week and asked whether it was real. It said that for certain services her surgeons had requested at least five times in 2025 with an approval rate of 90 percent or better, prior authorization would no longer be required for fully insured Colorado commercial members starting May 1, 2026. It listed the services. It was real. It was also the first time anyone in her office had seen gold carding prior authorization exemptions on anything but a legislative alert.
Aetna's April 2026 OfficeLink Updates newsletter announced the program: a prior authorization exemption, which the industry calls gold carding, for fully insured Colorado commercial plan members, identified by "CO DOI" on the member ID card, consistent with Colorado law. Providers who submitted at least five prior authorization requests for a specific service or drug in the prior calendar year and had 90 percent or more approved qualify for an exemption from requesting authorization for that service or drug. Aetna sent letters in April telling providers whether they qualified.
Gold carding prior authorization is spreading state by state and payer by payer, and the mechanics are similar everywhere. Here is how it works, where it exists, what the exemption does and does not do, and how a practice puts itself in a position to earn one.
Key takeaways
- Gold carding exempts a provider from prior authorization for a specific service when the provider's recent approval rate for that service meets a threshold, typically 90 percent over a defined lookback period with a minimum number of requests.
- Aetna's Colorado program begins May 1, 2026 for fully insured commercial members; exemptions are per provider and per service, and they were communicated by letter in April.
- Texas passed the first gold card law in 2021; Colorado, Arkansas, Louisiana, West Virginia, Wyoming and others have followed with different thresholds and lookbacks, and some payers run voluntary national programs.
- An exemption removes the authorization step, not the payer's right to review medical necessity afterward, so documentation standards should not change.
What gold carding prior authorization is
A glossary line first: prior authorization is a payer's requirement that a provider obtain approval before a service is performed, or the claim will deny (usually CO-197). A gold card is an exemption from that requirement, earned by a track record of requests that were approved anyway. The logic is that if a provider's requests for a given service are approved 90 percent of the time, the authorization step is producing little except delay and administrative cost, and the payer can skip it for that provider and that service.
The exemption is specific in three ways. It is per provider, usually per individual NPI, though some laws and programs now evaluate group practices. It is per service, defined by CPT or HCPCS code or by a service category. And it is for a period, typically renewed or re-evaluated each year, and revocable if the payer's later review finds the services did not meet its criteria.
What the exemption does: it lets the practice schedule and perform the exempted service without submitting an authorization request, and the claim should not deny for lack of authorization. What it does not do: it does not exempt the service from medical necessity review, from coverage rules, from network requirements, or from the possibility of retrospective audit. A gold-carded knee arthroscopy on a patient whose record does not support it is still a denial waiting to happen, just a later one.
Aetna's Colorado program
The Aetna program applies to fully insured Colorado commercial plans, which is narrower than it sounds. Self-funded employer plans, which Aetna administers but does not insure, are governed by federal law rather than state insurance law and are not included; neither are Medicare Advantage or Medicaid plans. The "CO DOI" marker on the ID card is how front desk staff can tell. The eligibility test is five or more requests for a specific service or drug in the prior calendar year with a 90 percent or higher approval rate. Qualifying providers received letters in April listing the exempted services, and the exemptions take effect May 1, 2026.
Practices in Colorado should do four things with the letter. Confirm which NPIs and which services it covers. Load those combinations into the practice management system as authorization-exempt for Aetna fully insured members, so the authorization work queue stops generating tasks for them. Keep the letter with the payer contract file, because when a claim denies for authorization anyway, the letter is the appeal. And keep submitting authorizations for everything not on the letter and for every other Aetna product; the exemption is exactly as wide as the list.
Practices outside Colorado should read the program as a preview. Aetna is implementing a state law; other payers in Colorado are subject to the same law, and other states have laws of their own with different numbers.
Where gold carding exists
| Program | Who it covers | Threshold and lookback | Notes |
|---|---|---|---|
| Texas (HB 3459, 2021; amended by HB 3812, 2025) | State-regulated commercial plans | 90 percent approval; lookback moved from six months to one year effective September 1, 2025; at least five requests | First gold card law in the country; the model most others adapted |
| Colorado | Fully insured commercial plans regulated by the Division of Insurance | Per Aetna's implementation: five or more requests in the prior calendar year, 90 percent approved | Aetna program effective May 1, 2026; other carriers implement the same statute |
| Arkansas, Louisiana, West Virginia, Wyoming | State-regulated plans | Vary by state; several adopted or amended programs in 2025 to extend to group practices or lengthen lookbacks | Check the state insurance department's guidance for the current rule |
| Payer voluntary national programs | Commercial members of the payer, varies by product | UnitedHealthcare's national program, launched October 1, 2024, uses a two-year lookback with a minimum request count and a high approval threshold for specific codes | Voluntary programs can change terms with notice; watch the payer bulletin |
The table is a snapshot, and the numbers move. Texas rewrote its lookback in 2025. Several states have bills pending. Payers adjust their voluntary programs annually. The practice-level habit is to check each state law and each major payer's program once a year, in the same review as the payer contracts.
Separately, UnitedHealthcare announced on April 20, 2026 that it would eliminate most medical prior authorizations nationally, with details to follow. That is a different mechanism from gold carding, since it removes the requirement for everyone rather than for providers with a track record, and we will write about it when the specifics are published. The direction is the same: payers are under legislative and public pressure to cut authorization volume, and gold carding is the version of that pressure that rewards practices with clean records.
Earning an exemption: the approval log
Every gold card program measures the same thing: your approval rate per service over a lookback period. A practice that does not track its own rate cannot know whether it qualifies, cannot challenge a payer's calculation, and cannot see which services are close to the threshold. The tool is a prior authorization log, and most practices already have one that is missing two columns.
The log needs, for each request: payer, member product (fully insured, self-funded, MA, Medicaid), provider NPI, service code, date submitted, date decided, decision, and if denied, whether the denial was overturned on appeal. From that you can compute, per payer per provider per code, the approval rate over any lookback, and the request count. Sort by codes with high volume and approval rates between 85 and 95 percent: those are the ones where a few cleaner requests, or a few appealed denials, move the practice over the line.
Appealed denials matter more than people realize. Some laws and programs count a denial overturned on appeal as an approval; some do not. Either way, an unappealed denial for a service that met criteria is a mark against the rate that did not need to be there. A practice that appeals wrongly denied authorizations is building its gold card record as well as getting patients treated. Practices that outsource authorization work to a denial and authorization team should ask for the approval rate by code as a standard report.
Operating with an exemption
Once a service is exempt, the temptation is to relax the documentation. Do not. Medical necessity criteria still apply, and payers retain the right to review claims retrospectively; some laws require the payer to evaluate a sample of exempted claims periodically to decide whether the exemption continues. A practice whose exempted services fail retrospective review loses the card and may face recoupment. Keep the same clinical documentation standard you used to win the authorizations in the first place.
Front desk and scheduling need to know the exemption exists and its boundaries: which payer, which product marker on the card, which providers, which codes. A scheduler who cancels a procedure because "we do not have an auth" for an exempt service has created the delay the exemption was meant to remove. A scheduler who assumes every Aetna patient is exempt has created a denial. Put the exemption list where they can see it.
Questions we hear
We are in Colorado and did not get a letter. Does that mean we do not qualify?
Possibly, or possibly the letter went to an address on file that nobody checks. Call Aetna provider relations, confirm the mailing address in your record, and ask for your approval rates by service for 2025. If you believe you met the threshold and were not exempted, the state law typically provides a process to dispute the determination.
Does a gold card in one state help us in another?
No. State laws apply to plans regulated by that state, and payer programs are specific to the payer's products. A multi-state practice needs to track each state's rule and each payer's program separately, by the NPI and location that requested the services.
Should we submit authorization requests anyway for exempt services, just to be safe?
Some payers will accept and process them; some will return them as unnecessary. Submitting requests you do not need adds work and, in some programs, dilutes nothing but your time. Our view is to trust the letter, load the exemption into the system, and keep the letter ready as the appeal document. Honestly, the risk of a wrongful authorization denial on an exempt service is small and easily reversed.
What to do this week
- If you are in Colorado, find the Aetna letter (or confirm none arrived) and load the exempted provider and service combinations into the practice management system.
- Add product type and appeal outcome columns to your prior authorization log if they are missing.
- Compute your approval rate by payer, provider and code for 2025 and flag services between 85 and 95 percent.
- Check your state's insurance department for a gold card statute and your top three payers' bulletins for voluntary programs.
- Brief the schedulers on which patients, providers and services the exemption covers, and post the list at the authorization workstation.
