Gold Card Program (GCP)

Select Health Gold Card Program uses Cave Consulting Group software to:

• Analyze practice patterns against national benchmarks for various condition-specific care measures.
• Offer Gold Carding (preauthorization leniency) for providers who most closely meet these benchmarks.
• Develop specialty-specific physician effectiveness scores based on this analysis. These scores will compare individual physician effectiveness against peer group effectiveness and relevant best-practice guidelines for their specialty.

Select Health also uses Healthcare Effectiveness Data and Information Set (HEDIS) performance to analyze the quality of the care being delivered. (Colorado only)

Currently, the GCP focuses on:

Program Goals

1. Review specific procedures related to preauthorization in a clinically based process, which is far more relevant to patient care.
2. Identify providers who can be rewarded with a more lenient preauthorization process when specific standards apply to a given practice.

Measurement

Specialists: To measure effectiveness, the Cave software assigns nearly all claim lines to a medical condition episode of care, resulting in accurate capture and assignment of costs. These episodes are:

• Assigned to providers with >20% of professional allowed charges
• Grouped by medical condition associated with a clinical measure
• Compared with protocol ranges based on nationwide utilization and published evidence-based care models

We measure performance on a group level based on a provider’s primary clinic in our records. There is a great deal of nuance to this information including:

• Attribution if a provider practices in multiple clinics
• Severity of illness
• Definition of diagnosis
• Attribution of tests

Primary Care: Measuring quality of care, the providers are scored on cumulative performance of meeting stretch goals in >75% of clinic eligible measures in Quality Provider Program (QPP) with a minimum of 5 eligible measures with at least 5 members in the measure. (Colorado only)

Program Evolution

Select Health will continue to prioritize potential savings via utilization review/utilization management (UR/UM) using vetted, approved, clinically appropriate thresholds. In addition to preauthorization leniency for cost-efficient practice patterns, we will focus additional efforts on those providers who are outside the benchmark thresholds.

This data will be reviewed at least twice a year with changes made to the preauthorization leniency list yearly. In some cases, the current threshold for preauthorization leniency is still inconsistent with national standards; thus, these thresholds will be adjusted over time to become more consistent with the national benchmarks. Select Health will provide ongoing feedback on medical condition practice patterns in comparison to peers within the region and nationally.

Continued qualification may be subject to post-service audits. Providers can also expect random chart audits over the year of leniency to ensure that the physician performed procedures meet the policy criteria for the procedure.

Important Exclusions

There are a few exclusions that you need to be aware of:

• GCP only applies to otherwise-covered services. Some services are excluded by specific plans and would still not be covered.
• Cosmetic procedures will continue to be denied as a plan exclusion, and unspecified codes will continue to be reviewed.

Communication

Select Health sends email updates of your provider group’s mid-cycle and year-end status and supports providers seeking to improve performance and program participation.

Questions?

For questions about the Gold Card Program please contact Mary.Suchyta@selecthealth.org (Utah) or Krista.Schonrock@selecthealth.org (Colorado).

Gold Card Program Reporting (Colorado Only)

View quarterly reports for the Colorado GCP (first report will be loaded after Q1 2026).