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 will take 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.

Questions?

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

Provider Support: Finding the Right Contact
Provider Services: Call 1-844-477-8313
Secure Provider Portal: Visit the Secure Provider Portal to check member eligibility, submit claims and more.
Provider Engagement: Use the Find Your Account Manager tool to find the Provider Engagement Account Manager (PEAM) supporting your specialty and region.
Claim Concerns: Resolve outstanding claims using the Claim Concerns form.
Provider News: Bookmark Provider News to keep up with the latest updates.
Provider Newsflash: Subscribe to our e-newsletter to get regular updates.
Provider Resources: Visit Manuals, Forms and Resources to find provider manuals, important forms, scheduling standards and other resources.

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