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Authorization Submission Updates

Date: 11/03/21

Fort Lauderdale, Florida

Sunshine Health is excited to announce we completed our integration with Staywell Health Plan. This includes the integration of Children’s Medical Services (CMS) Health Plan, which is now operated by Sunshine Health. The transition details can be found on our Integration Page.

Here are key billing and Utilization Management (UM) tips to address and/or expedite your request(s):

  • Sunshine Health implemented several new UM vendors. Please refer to the list on our Vendors Page for the services they provide and their contact information.
  • If you submitted authorization request via phone or through the Secure Provider Portal, please do not resubmit the request as a duplicate request may delay processing. We are working diligently to review all authorization requests.
  • Providers may submit prior authorization requests through our Secure Provider Portal.
  • Providers can also use our Pre-Auth Check Tool to see if a pre-authorization is needed.
  • CMS Physical, Occupational, and Speech Therapy authorization renewals should be requested through EviCore under Sunshine Health. WellCare is no longer accepting authorization requests.

As a reminder, Applied Behavioral Analysis (ABA) services continue to require prior authorization. All Medicaid ABA authorization requests should continue to go to EQHealth for CMS Title 19. ABA authorizations for CMS Title 21 members should be sent to health plan for further processing.

Below are the most frequently asked about codes:

  • H2017- no prior authorization
  • T1017- no prior authorization
  • H0038- requires prior authorization
  • H2019 BA – no prior authorization. This code will be monitored in our Outpatient Outlier Program.
  • H2014 BA- requires prior authorization
  • H2021 BA – requires prior authorization
  • H2020 BA- requires prior authorization

For claims submission guidelines and correspondence address information, please refer to the Guidelines for Proper Claims Submissions  on our Provider News page.

We value your partnership and look forward to your cooperation to ensure Sunshine Health members continue receiving high quality, cost-effective care.

If you have any questions, please contact Sunshine Health Provider Services at 1-844-477-8313, Monday through Friday from 8 a.m. to 8 p.m. Eastern.