What the Texas gold card law does
Texas gold card prior authorization rules let a physician skip prior authorization for a specific service when a health plan has approved nearly all of that physician's requests for it. The Texas gold card law began as House Bill 3459, passed by the 87th Legislature in 2021, and it applies to state-regulated HMO and PPO/EPO plans. In 2025, House Bill 3812 changed how exemptions are evaluated.
The idea is simple: if a plan approves a physician's requests for a service almost every time, the review step adds delay without changing the outcome. A "gold card" removes that step for that service with that plan, until the plan shows the physician no longer qualifies.
The exemption is narrow. It is earned service by service and issuer by issuer, so a physician can hold an exemption for one procedure with one plan and still need prior authorization for everything else.
How a Texas gold card prior authorization exemption is earned
Under the statute, a plan evaluates a physician's preauthorization requests for a particular health care service over an evaluation period. If at least 90 percent of the eligible requests were approved, the physician qualifies for an exemption for that service.
| Element | Original law (HB 3459, 2021) | After HB 3812 (effective Sept. 1, 2025) |
|---|---|---|
| Approval threshold | At least 90 percent of requests approved | At least 90 percent (unchanged) |
| Evaluation period | Six months | 12 months |
| Minimum volume | Five eligible requests, set by TDI rule | At least five eligible requests for the service (unchanged) |
| Data used | Preauthorization requests | All requests to the issuer or its affiliates, across the plans it issues or administers |
Under the original law, plans ran evaluations twice a year. The move to a 12-month period means fewer evaluation cycles and a larger sample for each physician. HB 3812 also directs TDI to collect preauthorization exemption data each year, and TDI said it would adopt rules to carry out the changes. Check TDI's current rules for the exact evaluation calendar and notice deadlines that apply to your plans.
What the plan must tell you
When a physician qualifies, the plan sends a notice naming the service covered by the exemption. The exemption starts when that notice is issued. Keep these notices with your payer contracts, because staff will need them when a plan's system still asks for an authorization on an exempt service.
Keeping or losing the exemption
A plan cannot simply drop an exemption. It must run a retrospective review of a random sample of the physician's claims for the exempt service (the original rules set a sample of five to 20 claims, and all claims are reviewed when fewer than five are available), and it can rescind only if the review shows the physician would not have met the 90 percent standard.
- The plan reviews the medical records behind the sampled claims, not just the claim lines.
- If it decides to rescind, it must give the physician written notice of the decision.
- A physician can ask an independent review organization to review a rescission, and under HB 3812 a denial of an exemption decided after September 1, 2025 can also go to independent review.
- Under the amended law, a plan may rescind an exemption only during January, and only after the first anniversary of the last day of the most recent evaluation period.
Documentation is what decides a rescission review. Notes that clearly support medical necessity for the exempt service are the best protection, because the reviewer is checking whether each sampled service would have been approved if it had gone through prior authorization.
Which plans and services the law reaches
The exemption applies to coverage regulated by the Texas Department of Insurance, including the state employee and teacher plans, and TDI notes that providers other than physicians, such as groups and facilities, can also qualify under their NPI. Coverage outside TDI's authority follows its own rules.
| Coverage | Gold card exemption? | Notes |
|---|---|---|
| Fully insured HMO and PPO/EPO plans regulated by TDI | Yes | Exemption is per service and per issuer |
| Self-funded employer plans (ERISA) | Not required by state law | Some administrators extend Texas exemptions to certain self-funded groups; confirm with the plan |
| Medicare Advantage | No | Federal Medicare Advantage rules apply |
| Texas Medicaid and CHIP | No | Medicaid managed care follows state Medicaid contract rules |
The exemption covers the prior authorization step only. Eligibility, benefit limits, coding rules, referral requirements and timely filing still apply. An exempt service can still be denied for reasons unrelated to medical necessity, such as a terminated policy.
BCBSTX prior authorization basics
Blue Cross and Blue Shield of Texas is one of the largest commercial plans in the state, so its process is a good example of how prior authorization works day to day. BCBSTX prior authorization starts with an eligibility and benefits check through Availity or a preferred vendor, which shows membership, network status and whether the service needs authorization.
- Check eligibility and benefits for the member and the specific service before scheduling. Our eligibility verification page explains what that check should capture.
- Find the right prior authorization list. BCBSTX publishes separate lists for fully insured and administrative-services-only (ASO) plans, Medicare Advantage plans and designated groups such as the Employees Retirement System of Texas.
- Submit the request through the channel the list names. Many requests go through Availity Authorizations & Referrals; certain services route to vendors such as eviCore healthcare or Carelon Medical Benefits Management.
- For services that do not require prior authorization, consider a Recommended Clinical Review, which lets the provider send clinical information ahead of time to reduce the risk of a retrospective medical necessity denial.
- Record the authorization number, approved units and date range on the claim.
BCBSTX states that if a required authorization is not obtained, the service may not be covered and the in-network ordering or servicing provider is responsible. Its provider site also notes that physicians may qualify for Texas exemptions for certain fully insured and ASO groups, so check exemption notices before submitting a request that may not be needed.
Practical steps for Texas practices
- Track approval rates by service and by plan, so you know which services are close to the 90 percent threshold.
- Check the plan's current list before submitting, and avoid requests for services that do not need authorization.
- Keep a list of current exemptions, the issuing plan and the notice date, and share it with scheduling and billing staff.
- Prepare documentation templates that support medical necessity for high-volume services, because rescission reviews read the chart.
- Calendar the plan's evaluation and notice dates once TDI's rules under HB 3812 are final.
Payment timing for authorized services follows the state's prompt pay rules, covered in our Texas Prompt Pay Act guide. For the wider claim cycle, see the medical billing process guide.
Prior authorization support
Gold card tracking is easier when every request, approval and denial is logged by service and plan. Fastora's prior authorization services cover request submission and follow-up, handled by certified billing professionals, and a free billing assessment can show where authorization gaps are causing denials.
Frequently asked questions
What is the Texas gold card law?
It is a state law, first enacted as HB 3459 in 2021, that exempts a physician from prior authorization for a specific service with a specific state-regulated plan when at least 90 percent of the physician's requests for that service were approved during the evaluation period.
How often are gold card exemptions evaluated?
The original law used six-month evaluation periods. HB 3812, effective September 1, 2025, moved to a 12-month evaluation period, kept the minimum of five eligible requests and limited rescissions to January. Check TDI's current rules for the exact calendar plans must follow.
Does a gold card exemption apply to all of a physician's services?
No. Each exemption covers one health care service with one plan issuer. A physician can hold exemptions for some services and still need prior authorization for others with the same plan.
Does the Texas gold card law apply to Medicare Advantage or Medicaid?
No. It applies to plans regulated by the Texas Department of Insurance. Medicare Advantage follows federal rules and Texas Medicaid managed care follows state Medicaid contract rules. Some self-funded groups may extend exemptions, so confirm with the plan.
