Performance-Based Gold Card Program
Recognizing High-Performing Providers
At Centene, we value the commitment providers make every day to deliver quality care and improve health outcomes for our members. Our National Performance-Based Gold Card Program recognizes participating providers who consistently demonstrate strong prior authorization approval performance for select outpatient services.
The program is designed to reduce administrative burden, streamline workflows, and support timely access to care for members.
How the Program Works
Providers who qualify for the Performance-Based Gold Card Program may no longer be required to obtain prior authorization for designated outpatient services included in the program. Instead, providers submita pre-notification before rendering eligible services.
Once the required pre-notification is submitted, providers may proceed with Gold Card eligible services without waiting for an authorization determination.
Pre-notifications must be submitted through Availity, or through the Evolent portal for services managed by Evolent.
Program Benefits
- Reduced administrative burden for designated services
- Fewer prior authorization requests
- More efficient workflows for provider offices
- Faster care coordination and treatment planning
Eligibility
Participation is by invitation and based on established program criteria and performance standards. Eligibility is assessed at the Ordering/Referring Tax Identification Number (TIN) level using historical utilization management performance data.
Providers who meet eligibility requirements may be periodically reviewed to ensure continued compliance with utilization management, billing, and program integrity expectations.
Important Information
The Gold Card Program applies only to designated outpatient services identified by Centene. The program does not apply to inpatient services or services outside the defined Gold Card scope. Participation does not waive requirements related to:
- Medical necessity
- Member eligibility
- Benefit coverage
- Network participation
- Claims submission requirements
Centene reserves the right to conduct utilization review, audits, and program integrity activities in accordance with applicable federal and state requirements.
Providers selected for participation will receive additional information regarding eligible services, operational requirements, and implementation timelines.