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Important information about prior authorizations for Durable Medical Equipment (DME)

Date: 01/27/22

Fort Lauderdale, Florida

NOTE: Please see update to this news item.

Thank you for your partnership with Sunshine Health and Children’s Medical Services Health Plan. As part of our commitment to deliver the most up-to-date information, we want to share important information about prior authorizations for Durable Medical Equipment (DME):

  • We are waiving prior authorizations for the following covered DME services with dates of service 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 between $5,000 and $10,000.
      • All items under $5,000 will require vendor approval.
      • All items exceeding $10,000 will require Sunshine Health approval.
    • All Long-Term Care (LTC) Members for items with total invoice or total rental reimbursement under $10,000
      • All items exceeding $10,000 will require Sunshine Health approval.
  • 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 given or necessary.
  • A retrospective review will be performed by a vendor after the waiver expires to ensure items provided were medically necessary and appropriately billed.
  • 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.
  • Please share this communication with your appropriate staff.

For questions or concerns, please contact Sunshine Health Provider Services at 1-844-477-8313.