"Gold Card" appeals under Act 511 of 2025

AID AMIJCLILS orsuuJocit * * Bulletin No. 4-2026 DEPART OM Mee 0 Hugh McDonald SECRETARY OF COMMERCE Jimmy Harris COMMISSIONER, ARKANSAS INSURANCE DEPARTMENT To: All Licensed Healthcare Insurers, Health Maintenance Organizations, Hospital Medical Service Corporations, Arkansas State Medical Board, Arkansas State Board of Pharmacy, and Other Interested Parties From: Arkansas Insurance Department Date: February 24, 2026 Subject: "Gold card" appeals under Act 511 of 2025 This bulletin replaces Bulletin 16-2024, which described the processes for appeals under Arkansas' "gold card" statutes. This bulletin amends the appeals processes to comply with Act 511 of 2025. Pursuant to Ark. Code Ann. § 23-99-1103(23): "Gold card program" means the process described in §§ 23- 99-1120 — 23-99-4126 under which a healthcare provider may qualify for an exemption from a healthcare insurer's or pharmacy benefits manager's prior authorization requirements. The first section of this bulletin describes the procedure for handling the independent review described by Ark. Code Ann. § 23-99-1123 of a healthcare insurer's decision to rescind a provider's gold card for a healthcare service. The second section provides a procedure for the independent review of a decision made pursuant to Ark. Code Ann. § 23-99-1128 by the Arkansas State Board of Pharmacy and the Arkansas State Medical Board to deny a request by a healthcare insurer or pharmacy benefits manager to exempt a prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service ("prescription drug") from its gold card program. Arkansas Department of Commerce Arkansas Insurance Department 1 Commerce Way, Suite 102 • Little Rock, AR 72202 INSURANCE.ARKANSAS.GOV Section 1. Appeal of a Healthcare Insurer's Decision to Rescind a Provider's Gold Card for a Healthcare Service. A. If a healthcare insurer rescinds a healthcare provider's gold card, the healthcare provider has a right to appeal that decision to an independent review organization. A healthcare provider must appeal within twelve (12) months of receiving proper notice of the recission. B. The healthcare provider shall file the appeal in accordance with the healthcare insurer's instructions, as described in Ark. Code Ann. § 23-99-1122(a)(2)(B)(ii), (iv), and (v). C. When filing the appeal, the healthcare provider may request review of a second random sample of claims, as authorized under Ark. Code Ann. § 23-99-1123(d)(1), if the claims information required by Ark. Code Ann. § 23-99-1122(a)(2)(B)(iii) identified that at least five (5) additional claims were eligible for review but not included in the original random sample. D. Immediately upon receipt of the healthcare provider's appeal request, the healthcare insurer shall complete a preliminary review of the appeal request to determine whether: i. The healthcare provider has provided all the information required by Ark. Code Ann. § 23-99-1122(a)(2)(B)(iv)(a)-(c); and ii. The healthcare provider's appeal is eligible for independent review under Ark. Code Ann. § 23-99-1123(a)(3), which reads: A healthcare provider who has an exemption rescinded due to a failure to provide medical records within sixty (60) days of a record request for a retrospective review shall not be eligible for review of that rescission by an independent review entity. E. The healthcare insurer shall immediately notify the Insurance Commissioner in writing at aid.goldcardexemption@arkansas.gov and the healthcare provider in writing regarding whether the appeal request: i. Is complete; and ii. Is eligible for independent review under Ark. Code Ann. § 23-99-1123(a)(3). F. If the appeal request is not complete: i. The healthcare insurer shall inform the healthcare provider and the commissioner in writing of the deficiency no later than two (2) business days from the receipt of the appeal request and shall describe in the notice the information or materials needed to complete the request; Page 2 of 6 ii. The provider shall have no more than one (1) business day to provide the requested materials; and iii. The healthcare insurer shall then have one (1) business day to review the additional materials for completeness and repeat the above-described steps in Section 1(E) and, if necessary, Section 1(F). G. Within two (2) business days of receipt of the notice that an appeal is eligible for independent review and complete, the commissioner shall: i. Assign an independent review organization from the list of approved independent review organizations compiled and maintained by the commissioner to conduct the review, pursuant to 23 CAR § 117-111; ii. Notify the healthcare insurer of the name and contact information of the assigned independent review organization; and iii. Notify the healthcare provider of the name of the assigned independent review organization. H. Upon receipt of the name and contact information for the assigned independent review organization, the healthcare insurer shall provide to the assigned independent review organization: i. The information described in Ark. Code Ann. § 23-99-1122(a)(2)(B)(iii); ii. Copies of any medical records and documents described in Ark. Code Ann. § 23-99-1122(c)(1); and iii. Any other documents and other information the healthcare insurer considered in making its decision to rescind the healthcare provider's gold card. I. If the healthcare provider requested that the independent review organization consider a second random sample of claims, the healthcare insurer shall have two (2) business days after receiving the name and contact information for the assigned independent review organization to provide the assigned independent review organization with a listing of all payable claims submitted by the healthcare provider for the same health care service during the evaluation period that were eligible to be evaluated but that were not included in the original random sample. The listing must be sufficiently detailed to allow the independent review organization to identify each payable claim to be used in the second random sample. J. If a second random sample is requested, the independent review organization shall immediately identify, from the list of eligible claims provided by the healthcare insurer, a second random sample of at least five (5) and no more than twenty (20) claims. Page 3 of 6 K. Once the independent review organization has identified the claims that will comprise the second random sample, the independent review organization shall in writing request the corresponding medical records from the healthcare insurer. The independent review organization shall provide the healthcare provider with written notice of the request. L. With a copy to the healthcare provider, the healthcare insurer shall provide the requested medical records to the independent review organization no later than two (2) business days from receipt of the independent review organization's request. M. The healthcare provider shall have no more than three (3) business days from the date it receives the healthcare insurer's response to provide the independent review organization with any additional medical records necessary for the independent review organization to review the second random sample of claims. N. The independent review organization shall determine whether to affirm or overturn the health care insurer's determination that less than ninety percent (90%) of the claims met the applicable medical necessity criteria by reviewing each claim that the healthcare insurer retrospectively reviewed and determined did not meet the applicable medical necessity criteria and, if applicable, each claim included in the second random sample identified by the independent review organization. O. An independent review organization shall complete a review of a gold card rescission no later than: i. Thirty (30) days after the date a healthcare provider files the request for a review, per Ark. Code Ann. § 23-99-1123(c); or ii. Sixty (60) days after the date a healthcare provider files the request for a review, if the healthcare provider requested a second random sample. P. Immediately after reaching its decision, the independent review organization shall notify the healthcare provider, the healthcare insurer, and the commissioner of its decision. Section 2. Appeal of a Decision Denying a Request to Exempt a Prescription Drug from a Gold Card Program A. If a healthcare insurer or pharmacy benefits manager requests a prescription drug be exempted from gold card programs pursuant to Ark. Code Ann. § 23-99-1128, and if the Arkansas State Board of Pharmacy and the Arkansas State Medical Board deny the request, then the healthcare insurer or pharmacy benefits manager may file an appeal to the State Insurance Department within ninety (90) days of the denial. Page 4 of 6 B. Before filing an appeal, the healthcare insurer or pharmacy benefits manager shall provide seven (7) days' notice to the Arkansas State Board of Pharmacy and the Arkansas State Medical Board of its intent to file an appeal, per Ark. Code Ann. § 23-99-1129(b). C. The healthcare insurer or pharmacy benefits manager shall file its appeal with the Insurance Commissioner by emailing aid.goldcardexemption@arkansas.gov and shall include: i. A copy of the written request, including any supporting documentation the healthcare insurer or pharmacy benefits manager sent the Arkansas State Board of Pharmacy for a prescription drug, medicine, biological product, pharmaceutical, or pharmaceutical service to be reviewed for exemption from the gold card program, as described in Ark. Code Ann. § 23-99-1128(b); ii. A copy of the criteria and procedures adopted by the Arkansas State Board of Pharmacy and the Arkansas State Medical Board, as described in Ark. Code Ann. § 23- 99-1128(b)(3); and iii. A copy of the Boards' decision, including any supporting documentation used to make the decision, as described in Ark. Code Ann. § 23-99-1128(b)(5), or that explains the decision. D. The healthcare insurer shall notify the Arkansas State Board of Pharmacy and the Arkansas State Medical Board in writing when the appeal is filed but need not include all attachments described above in Section 2(C)(i)-(iii). E. No later than the thirtieth day after the date a healthcare insurer or pharmacy benefits manager files the appeal, the commissioner shall appoint an independent review organization from the list maintained pursuant to 23 CAR § 117-111 to review the appeal and shall submit to the appointed independent review organization the information described above in Section 2(C)(i)-(iii). F. The assigned independent review organization shall review the information submitted under Section 2(C)(i)-(iii) when deciding whether to uphold or reverse the Boards' decision to deny the request to exempt the prescription drug from gold card programs. G. Within forty-five (45) days after the date it receives the appeal, the assigned independent review organization shall provide written notice of its decision to: i. The healthcare insurer or pharmacy benefits manager that filed the appeal; ii. The Arkansas State Board of Pharmacy; iii. The Arkansas State Medical Board; and Page 5 of 6 iv. The Insurance Commissioner. For questions related to this bulletin, please direct all inquiries to AID's Legal Division at (501) 371-2820 or email insurance.legal@arkansas.gov. Jimmy Harris Commissioner Arkansas Insurance Department Page 6 of 6