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Prior Authorization

How to Reach Prior Authorization Staff with an Authorization Request

When you need care, always start with a call to your PCP. Some covered services may need prior approval. They may need review by Sunshine Health before services are given. This includes services or visits to an out-of-network provider. Hospital stays, transplants, home health services, some surgeries, medical equipment and some medicines require prior approval. Your doctor can tell you if a service needs a prior approval. The list of these services can be found below.

You can also call Member Services if you have questions. The number is 1-855-463-4100.

Some covered services require a prior authorization from Sunshine Health before the service is provided. The list of services that need a prior authorization can include an admission to the hospital after your emergency condition has improved, power wheelchairs, home health visits, MRI X-rays, hospice care, genetic testing, pain management or some outpatient surgery. That list is on our website at Your PCP or other doctor that is treating you can request an authorization from Sunshine Health. When your doctor requests an authorization, he or she must send information about your health condition and treatment. This may include copies of your medical record, results of tests, what medications you have tried, or what kind of support you need to take care of yourself at home. You can go to any participating Sunshine Health doctor for covered services.

Your doctor will give us information about why you need the service. Sunshine Health will look to see if the service is covered and that it is necessary. Sunshine Health will make the decision as soon as possible, based on your medical condition. Standard decisions are made within seven calendar days. If the service is urgent, the decision will be made within 48 hours. We will let you and your doctor know if the service is approved or denied. If you or your doctor is not happy with the decision, you can ask for a second review. This is called an appeal. See the “Member Satisfaction” section in your Member Handbook. This will give you more information about appeals.

If there are any major changes to the prior authorization process, we will let you and your doctors know right away.

Prior Authorization List

Sunshine Health needs to approve in advance the services listed below. Prior approval is required for all services by a provider who is not in the Sunshine Health network. The only exception is for emergency care. Emergency room or urgent care visits do not require prior authorization.

Services Requiring Prior Authorization

PCPs, Specialists, or Facilities must request an authorization for the following services:

This list indicates what services require a prior authorization. If there is no prior authorization received from Sunshine Health, the claim for any service noted as needing a prior authorization will be denied. This is not a complete list of covered services. Limits and services that are not covered are listed in the Member Handbook. The utilization management department is available Monday through Friday from 8 a.m. to 6 p.m. at 1-855-463-4100, during normal working days. Nurse Advice Line staff are available 24/7 for after-hour calls.