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Sunshine Health Pre-Auth Check Tool and Physical Therapy (PT) Services

Date: 07/08/25

Sunshine Health wants to make Physical Therapy (PT) providers aware of an issue when submitting authorization requests for certain services.

The Pre-Auth Check Tool currently shows the incorrect prior authorization requirements for the codes listed below. The correct prior authorization requirements for these codes can be downloaded via the updated list of Medicaid Prior Authorization Changes (PDF) that took effect on September 1, 2024.

We are working diligently to correct the Pre-Auth Check Tool. But until this issue is corrected, PT providers should utilize the Medicaid Prior Authorization Changes (PDF).

Impacted codes

  • 97165
  • 97166
  • 97167
  • 97168
  • 97530
  • 97542
  • 97755
  • 97161
  • 97162
  • 97163
  • 97164
  • 97110
  • 97112
  • 92521
  • 92522
  • 92523
  • 92524
  • 92526

Timing 

  • The Pre-Auth Check Tool update may take several weeks to be completed.
  • Our Prior Authorization team is aware that providers should be referencing the requirements that went into effect in September 2024.

What should providers do? 

  • Providers using any of the above codes need to follow the prior authorization requirements listed in the PDF, not the pre-auth check tool.
  • Once the Pre-Auth Check Tool update is completed, we will inform providers.

Please contact your Provider Engagement Account Manager (PEAM) further if you need assistance.

Questions?

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

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