New Important Update about Prior Authorizations for Durable Medical Equipment (DME)
Date: 02/22/22
Fort Lauderdale, Florida
We want to share an important update about prior authorizations for Durable Medical Equipment (DME) to expedite services for members.
- We are waiving prior authorizations for the following covered DME services with dates of service from October 1, 2021, through March 31, 2022:
- All Sunshine Health Medicaid, Serious Mental Illness Specialty Plan (SMI), Child Welfare (CW) and Children’s Medical Service (CMS) Health Plan members for items with total invoice or total rental reimbursement greater than $5,000.
- All items under $5,000 will require vendor approval.
- DME items for Long-Term Care (LTC) Members will not require an authorization.
- All Sunshine Health Medicaid, Serious Mental Illness Specialty Plan (SMI), Child Welfare (CW) and Children’s Medical Service (CMS) Health Plan members for items with total invoice or total rental reimbursement greater than $5,000.
- Providers will be paid according to their contracted rates. Any DME that is not on the fee schedule or manually priced, such as miscellaneous codes, will be paid at 60% of billed charges. No single case agreements (SCAs) will be necessary.
- Action needed: Please do not submit requests for the above listed services.
- For any requests that were already submitted through Sunshine Health’s Secure Provider Portal or via fax, the provider will receive a notice that no auth needed for dates of service.
- Sunshine Health will pay claims submitted during those dates of services. It could take up to three days after submission for providers to see a final claims disposition in the Secure Provider Portal.
Due to the waiver of authorization, there will be no recoupments on these claims related to medical necessity by Sunshine Health or any contracted entity. This does not, however, eliminate the responsibility of the provider in ensuring the patient meets medical necessity per established policy for the items being provided. Sunshine Health will conduct audits on claims impacted by this authorization waiver in cases of fraud only.
Providers who suspect and witness inappropriate billing or inappropriate services for a member are encouraged to call the anonymous and confidential FWA hotline at 1-866-685-8664 or contact the compliance officer by phone at 1-866-796-0530 or by email at compliancefl@centene.com.
Please share this communication with your appropriate staff. For questions or concerns, please contact Sunshine Health Provider Services at 1-844-477-8313.
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