Important Prior Authorization Updates
Date: 07/14/26
As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Sunshine Health wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.
Code change details can be found below. 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.
Service Category | PA Rule | Services | Procedure codes |
|---|---|---|---|
| Behavioral Health | No PA Required | Behavioral Assessment | 96121 |
DME Services | No PA Required | Orthotic and Prosthetic | L5000, L5704 |
Drug Codes | No PA Required | Diabetic Drugs and Supplies | A4238 |
Genetic Analysis | No PA Required | Genetic Testing | 81161, 81200, 81206, 81207, 81219, 81240, 81241, 81242, 81243, 81250, 81251, 81255, 81256, 81260, 81279, 81297, 81304, 81319, 81338, 81339, 81372, 81374, 81375, 81378, 81381, 81382, 81383, 81400, 81401, 88230, 88280, 88291 |
Hearing Services | No PA Required | Implants and Supplies | L8624 |
Home Services | No PA Required | Other Services | H0045 |
Home Visit | S9213 | ||
Nursing Services | T1001 | ||
Hospice | PA Required | Hospice Services | 651 |
Other Medical Services | No PA Required | Dental Care | G0330 |
Physician Services | No PA Required | Diagnostic Testing | 91113 |
Sleep Medicine | No PA Required | Sleep Studies | 95805 |
Surgery Procedures | PA Required | Tonsil and Adenoid Procedures | 42821, 42826, 42831 |
Transportation Services | PA Required | Medical Transportation | A0130 |
Questions?
Sunshine Health has a wealth of resources available to help answer your questions and address your concerns:
- Provider Support Guide: Find 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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