Prior Authorization Notification
Date: 09/01/21
Fort Lauderdale, Florida
As part of our ongoing integration efforts to combine the best of both Sunshine Health and WellCare health plans, we have reviewed policies and processes regarding prior authorization. The goal of our combined company is to ensure the highest quality care for our members in partnership with our providers.
The notification is to advise you that at this time, the plans are aligned on which services do and do not require a prior authorization and there are no significant changes.
The information below applies to our Medicaid (Sunshine Health and Staywell Medicaid and Long Term Care), Child Welfare Specialty Plan, Serious Mental Illness Plan and Children’s Medical Services Health Plan products. Any deviations by product are noted below.
The health plan suggests utilizing the prior authorization check tool on our website to verify if an authorization is required:
The services listed below require a prior authorization:
- Inpatient facility admissions, inpatient hospice, detox, SNF and Other Post-Acute Care Services
- SIPP (Statewide Inpatient Psychiatric Program)
- Inpatient psychiatric admissions
- Air transport
- NEMT with non-participating providers
- Hospice care
- DME and O&P
- NEMT over 100 miles
- Inpatient detox admissions
- Genetic testing
- Non-medical NEMT transport for CW members
- Ambulatory detox
- Home health and home infusion
- Pain management programs and services
- Select Behavioral Health Community - based services
- Private duty nursing
- Potentially cosmetic surgery
- Partial hospitalization
- OT, PT, ST
- Quantitative drug testing
- Hearing aids
- Procedures done in outpatient setting, ambulatory surgical center or office
- Implantable devices (cochlear implants)
- Family training and counseling for child development
- Multi-systemic therapy
- Sleep studies performed in the home
- Infant mental health testing
- Shingles vaccine
- High tech radiology
- Intensive outpatient therapy Mental Health
- Pneumonia vaccine
- Injectable drugs and drugs given by an MD in office setting, IV infusion
- Intensive Outpatient Program for Substance Use Disorder
- Therapeutic abortions
- Ambulatory surgery
- Transplants
- Dental or oral surgical procedures requiring general anesthesia
- Behavioral Health Residential outpatient treatment
- Applied Behavior Analysis (ABA) – Title 21
- Bariatric surgery
- Investigational/experimental
The services listed below do not require prior authorization:
- Mobile crisis assessment and intervention
- Behavioral health assessment services
- Medical foster care
- Early Intervention Services (EIS)
For questions or concerns, please contact your Provider Relations representative. You can also call Sunshine Health Provider Services at 1-844-477-8313.