Important Prior Authorization Updates

Date: 11/06/25

(Effective January 1, 2026)

Thank you for being a participating provider with Sunshine Health. As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, we want to share some important updates to our PA requirements. This work is aligned with broader industry efforts, driven by commitments to regulatory agencies and America’s Health Insurance Plans (AHIP), to modernize and streamline prior authorization. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.

These changes may include:

• Removing PA requirements based on criticality of review and clinical need.
• Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests.

If you have questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement Account Manager or contact Sunshine Health Provider Services at 1-844-477-8313.           

Therapeutic Behavioral Onsite Services (H2019) FAQ: Visit this resource for more information about prior authorization for onsite therapeutic behavioral services.                                                           

Prior Authorization Updates

Service Category	PA Rule	Services	Procedure Codes
Behavioral Health	PA Required	Treatment Services	90867, 90868, H2017, H2019  (H0, HN and HM modifiers only. HR, HQ modifiers and H2019 without a modifier will not require PA.)
	No PA Required	Evaluation Services	96130, 96136 (20 years of age and under)
Cardiovascular	PA Required	Heart Surgery	93656
DME Services	PA Required	Incontinence Supplies	T4521, T4522, T4523, T4524
	No PA Required	Wheelchairs	K0739
Drug Codes	PA Required	Injections	Q4081
	No PA Required	Diabetic Drugs and Supplies	A4232
		Injections	J1720, J2919
		Medications	J3489
		Other Services	S5199
Genetic Analysis	PA Required	Genetic Testing	81220
	No PA Required	Genetic Testing	81244, 81331
Hearing Services	PA Required	Implants and Services	V5261
	No PA Required	Implants and Services	V5299
Home Services	PA Required	Nursing Services	T1002
	No PA Required	Home Management	S9211, S9214
		Home Therapy	97157
		Respite Care	S9125
		Social Services	S9127
Other Medical Services	PA Required	Other Services	T1025
	No PA Required	Acupuncture	97810
		Other Services	97010, 97012, 97014, 97026, 97032, 97033, 97035, 97760, 97763
Skin Procedures	PA Required	Muscle Flap Procedures	15734
	No PA Required	Skin Grafts	15272
Surgery Procedures	PA Required	Abortion Procedures	59841
		Digestive System	49505, 49650
		Female Genitalia	58662
		Integumentary System	19301, 19357
		Male Genitalia	54360
	No PA Required	Digestive System	42975
		Eye and Ocular Adnexa	66821, 66850, 66985, 67108, 67113, 67311, 67312, 67314, 67800, 67801, 67808
		Vascular	36471, 36479
Transportation Service	PA Required	Medical Transportation	A0431, A0436
Vision Services	No PA Required	Other Services	V2799

 

H2019 Note: New PA requirements for H2019 apply only to: Therapeutic behavioral on-site services, therapy (H2019 HO); Therapeutic behavioral on-site services, behavior management (H2019 HN); and Therapeutic behavioral on-site services, therapeutic support (H2019 HM).                                           

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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