Arkansas Insurance Department issued revised procedures for gold card appeals on February 24, implementing Act 511 of 2025 and replacing repealed Bulletin 16-2024 with Bulletin No. 4-2026.
Arkansas’s gold card program permits qualifying healthcare providers to bypass prior authorization requirements imposed by insurers. In certain cases, exemptions also apply to Pharmacy Benefit Manager requirements.
Providers qualify by meeting defined approval-rate thresholds for specific services during a set evaluation period, as outlined in the Arkansas Code.
The updated bulletin defines two state-specific independent review pathways. One addresses rescission of a healthcare insurer gold card. The other applies to rescission involving a PBM after a healthcare or medication request.
For healthcare insurer rescissions, a provider may file an appeal to an independent review organization within 12 months of receiving proper notice.
Appeals must follow the insurer’s filing instructions. Providers may request review of a second random sample of claims if eligibility criteria are satisfied.
Once an appeal request is received, the insurer must conduct a preliminary completeness and eligibility review without delay.
Written notice must go to both the Insurance Commissioner, at the designated bulletin email, and the provider confirming whether the appeal meets requirements.
If incomplete, the insurer has two business days to issue a deficiency notice. The provider then has one business day to cure the deficiency. The insurer has one additional business day to reassess.
The bulletin assigns the Insurance Commissioner responsibility for selecting an independent review organization within two business days after confirming appeal eligibility.
Insurers must transmit required records and materials to the assigned IRO within two business days. Additional deadlines apply if a second random sample review is requested.
The IRO must complete its review within 30 days of the provider’s filing. If a second sample is involved, the deadline extends to 60 days. The IRO must issue notice of its determination to the provider, insurer and Insurance Commissioner.
For prescription drug exemption denials involving insurers or PBMs, the bulletin establishes a separate process. An insurer or PBM may appeal to the State Insurance Department within 90 days of denial.
The appellant must provide seven days’ notice of intent to appeal to both the Arkansas State Board of Pharmacy and the Arkansas State Medical Board. Filing requires emailing the Insurance Commissioner with specified documentation.
The Insurance Commissioner must appoint an IRO within 30 days of appeal filing. The IRO then has 45 days from receipt of the appeal to issue written notice of its decision to the appellant, both boards and the Insurance Commissioner.
According to Beinsure analysts, compressed procedural timelines and direct commissioner oversight introduce tighter compliance expectations for insurers and PBMs operating under Arkansas’s gold card framework.
