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Prior Authorization Requirements Update

Date: 05/02/25

Sunshine Health requires prior authorization (PA) as a condition of payment for many services. This notice contains information regarding such prior authorization requirements and is applicable to all Medicaid products offered by Sunshine Health.

Effective June 1, 2025, the following codes will no longer require prior authorization to be submitted to Sunshine Health:

  • E0601: Continuous positive airway pressure (CPAP) device
  • E0431: Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing
  • E0562: Humidifier, heated, used with positive airway pressure device
  • E1392: Portable oxygen concentrator, rental
  • A4256: Normal, low, and high calibrator solution/chips
  • E0443:  Portable oxygen contents, gaseous, 1 month's supply = 1 unit 
  • A4253: Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
  • A4259: Lancets, per box of 100
  • 81257: HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, Constant Spring)

Sunshine Health is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.

For complete CPT/HCPCS code listing, please see the Prior Authorization Tool.

The preceding codes included in the document represent the national, standard code sets. Inclusion or exclusion of a code does not constitute or imply subscriber coverage or provider reimbursement.

Please refer to your contract with Sunshine Health to determine all contracted/covered codes for each membership group. Please refer to the Medicaid Fee Schedule, and the Billing and Procedure Coding Guide for a list of approved modifier codes.

Questions?

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

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