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Member Handbooks and Forms

Prior Authorization List

Send request to the Utilization Management Department at:

  • Web request: Outpatient Medicaid prior authorization form at sunshinehealth.com
  • Fax: (866) 796-0526

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:

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 Sunshine Health’s website)
  •  Genetic Testing
  • Home health and home infusion (initial nurse evaluation visit does not require a prior auth)
  •  Occupational, physical, speech, or respiratory therapy:
    • Members under the age of 21 by HN1, except if service in a PPEC or hospital outpatient, by Sunshine Health
    • Members over the age of 21, no authorization needed
  • Quantitative Drug Testing for Drugs of Abuse
  • Notification of Pregnancy (NOP) form within 5 days of member’s first prenatal visit (fax completed NOP to (866) 681-5125)
  • Note: Labor checks do not require a prior authorization if performed in a Sunshine Health participating facility

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

  • Hospice care
  • Observation stays
  • Pain management programs or services
  • Radiology (by NIA):
    • CT, MRI, MRA, and PET scans o Fetal MRI
    • Intensity Modulated Radiation Therapy
    • Proton and Neutron Beam Therapy
    • Stereotactic Radiology
  • Sleep studies performed in a home environment

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
  • Adult pneumonia and shingles vaccine for ages 21 to 65
  • Any potentially cosmetic, experimental or investigational treatments or services, or clinical trials
  • Behavioral health or substance abuse services
  • 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
  • Post discharge meals

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 (866) 796-0530, during normal working days. Nurse Advice Line staff are available 24/7 for after-hour calls.

Revised: July 2016

Effective: August 2016