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Prior Authorization

How to Reach Prior Authorization Staff with an Authorization Request

When your child needs care, always start with a call to their Primary Care Provider (PCP). Some covered services may need prior approval. They may need review by Children’s Medical Services (CMS) Health Plan before services are given. This includes services or visits to an out-of-network provider. Hospital stays, transplants, home health services, medical equipment, some surgeries and medicines, require prior approval. A provider can tell you if a service needs a prior approval. The list of these services can be found below.

If you have questions, please call your child’s care manager or Member Services at 1-866-799-5321 (TTY 1-800-955-9770).

The list of services that need a prior authorization can include an admission to the hospital after an emergency condition has improved, power wheelchairs, home health visits, MRI X-rays, hospice care, genetic testing, pain management or some outpatient surgery. A PCP or other doctor that is treating your child can request an authorization from CMS Health Plan. When a doctor requests an authorization, he or she must send information about your child’s health condition and treatment. This may include copies of his or her medical record, results of tests, what medications he or she has tried, or what kind of support your child needs at home. Your child can go to any participating CMS Health Plan doctor for covered services.

The provider will give us information about why your child needs the service. CMS Health Plan will look to see if the service is covered and that it is necessary. CMS Health Plan will make the decision as soon as possible, based on your child’s 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 the doctor know if the service is approved or denied. If you or the doctor are 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 provides more information about appeals.

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

Prior Authorization List

CMS Health Plan needs to approve in advance the services listed below. Prior approval is required for all services by a provider who is not in the CMS Health Plan 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:

All acute and non-acute inpatient facility admissions, including: observations, inpatient hospice, behavioral health, skilled nursing facility, crisis stabilization and rehabilitation.

Timeframes for notification are:

  • 7 days prior to a scheduled or elective admission
  • Within 48 hours of an emergency admission
  • By next business day for a delivery

 

  • Air transport
  • Durable medical equipment and prosthetics (list of codes on CMS Health Plan’s website)
  • Genetic Testing
  • Home health and home infusion (initial nurse evaluation visit does not require a prior authorization)
  • Home visit by a clinical social worker
  • Occupational, physical, speech, or respiratory therapy:
    • Members under the age of 21 by HN1, except if service in a PPEC or hospital outpatient, by CMS Health Plan
    • Members over the age of 21 by HN1
  • Quantitative drug testing for drugs of abuse
  • Notification of Pregnancy (NOP) form within 5 days of member’s first prenatal visit 
  • Doula services
  • Note: Labor checks do not require a prior authorization if performed in a CMS Health Plan participating facility

Any covered potential transplant evaluation, pre-transplant care, transplant and post-transplant follow-up services

  • Hospice care
  • Pain management programs or services
  • Radiology (by NIA):
    • CT, MRI, MRA, and PET scans
    • Fetal MRI
    • Intensity modulated radiation therapy
    • Proton and neutron beam therapy
    • Stereotactic radiology
  • Sleep studies performed in a home environment
  • Medical foster care services

Procedures done in an outpatient hospital setting, ambulatory surgical center or an office, including:

  • Bariatric surgery
  • Dental or oral surgery procedures requiring general anesthesia
  • Implantable devices, including cochlear implants, reprogramming of cochlear implants and related services
  • Potentially cosmetic or plastic surgery, including but not limited to:
    • Blepharoplasty
    • Breast reconstruction or reduction
    • Varicose vein procedures
    • Septoplasty/rhinoplasty
    • Otoplasty
  • Therapeutic abortions
  • Nutritional counseling
  • Any potentially cosmetic, experimental or investigational treatments or services, or clinical trials
  • Behavioral health or substance abuse services including ambulatory detoxification, partial hospitalization, self-help peer services, OP therapy, group therapy, intensive outpatient therapy, infant mental health testing and Targeted Case Management
  • Behavioral Health - Art Therapy
  • Food and lodging for family of member admitted over 150 miles from home for specialty care
  • Injectable drugs and drugs given by a doctor in an office setting, and IV infusion drugs (list of codes on Sunshine Health’s website)
  • Non-emergency services with a non-participating provider
  • Home Delivered Meals - Post-Facility Discharge (Hospital or Nursing Facility)
  • Meals provided during non-emergency transportation greater than 100 miles
  • Massage therapy
  • Acupuncture

The list above indicates what services require a prior authorization. If there is no prior authorization received from CMS Health Plan, 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 1-866-799-5321, during normal working days. Nurse Advice Line staff are available 24/7 for after-hour calls.