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Authorization Frequency-Based Approvals Enhancement

Date: 04/10/26

Sunshine Health is enhancing its authorization matching logic to better align claims processing with the frequency approved on an authorization.

As part of this enhancement, when an authorization is approved with a defined frequency, such as weekly, the system will match and apply authorized units based on that approved frequency rather than viewing the total units as fully available across the entire authorization span.

This update is intended to better align claims adjudication with the structure of the approved authorization and ensure authorized units are available consistent with the frequency that was approved.

For example, if an authorization is approved for 40 hours per week, those units will be matched and available on a weekly basis. Claims submitted outside of the approved frequency or in excess of the units available for that frequency may deny consistent with authorization requirements.

This enhancement does not change the underlying medical necessity determination or authorization requirements. Rather, it improves the way approved authorizations are applied during claims processing to more accurately reflect the authorization as issued.

Providers should continue to:

  • Submit claims consistent with the approved authorization
  • Monitor utilization against the approved frequency and units
  • Request updated or additional authorization when services needed exceed the approved frequency or units

This change took effect on May 11, 2026.

We appreciate your partnership as we continue to improve our authorization and claims processes. If you have questions, please contact your Provider Engagement Account Manager.

Authorization Frequency-Based Approvals Enhancement Frequently Asked Questions (FAQ)

Why is this update being implemented?
This update is intended to better align claims adjudication with the structure of the approved authorization and ensure authorized units are delivered consistently with the frequency and intensity that was approved.

Does this enhancement change the medical necessity criteria or authorization requirements utilized?
This enhancement does not change the underlying medical necessity determination or authorization requirements. Rather, it improves the way approved authorizations are applied during claims processing to more accurately reflect the authorization as issued.

Which services are impacted?
This currently applies to Behavior Analysis (BA) services and the following CPT codes: 97153, 97154, 97155 and 97158.

Is 97153 XP included in the Authorization frequency-based approvals enhancement?
No, 97153 with the modifier XP is excluded.

How will 97155 be affected due to supervisor availability?
Supervision should be provided weekly and can be requested/provided up to 20% of direct services per Council of Autism Services Providers (CASP) guidelines.

When does this change take effect?
This is effective for Dates of Service on or after May 11, 2026, regardless of when the authorization was approved or whether the authorization is new or existing. Date of Service determines applicability.

Are authorizations being split into weekly authorizations?
No. Authorizations are not split into weekly segments in the system. The authorization remains intact. Even unit allocation is enforced during claims processing based on Date of Service.

How are units reviewed for payment?
Claims are reviewed against the authorized units available for each Date of Service. Payment is made only for units that fall within that even unit allocation.

What happens if more units are billed on a single day than authorized?
Only the units that exceed the even unit allocation for that day will be denied. The entire day's claim will not automatically be denied if some units are allowable.

Can unused units from earlier in the week be used later?
Authorized units are expected to be used evenly across the authorization period. Claims are matched based on the units available and the time elapsed.

Are providers required to submit authorizations differently?
No. There are no changes to authorization request submissions, clinical documentation requirements, or Utilization Management (UM) review processes.

Are approved authorizations being changed or reduced?
No. Authorizations are not modified after approval. Clinical determinations remain unchanged. Enforcement occurs during claims processing only.

What is the process if there is a change in the members’ clinical needs and more hours/units are needed?
Consistent with the standard authorization process, providers are responsible for monitoring changes in treatment intensity over the course of care. If clinical needs increase and additional units are required, the provider is expected to end the current authorization and submit a new authorization request based on the updated clinical information. Appeal rights are available if the request is denied.

How will providers know if units are denied?
Claims impacted by authorization splitting will reflect standard claims denial messaging indicating that billed units exceeded authorized limits for the Date of Service.

Who can I contact if I have questions?
Contact your Sunshine Health Provider Engagement Account Manager (PEAM) or call Provider Services at 1-844-477-8313. 

Questions?

Sunshine Health has a wealth of resources available to help answer your questions and address your concerns:

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