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Prior Auth Changes for Targeted Case Management (TCM) and Psychosocial Rehabilitation (PSR) Services

Date: 07/25/25

Starting August 1, 2025, Sunshine Health will require prior authorization for all Targeted Case Management (TCM) and Psychosocial Rehabilitation (PSR) services for members ages 4 years old and above.

This change will not apply to members under 4 years old. While this change will take place in August, the health plan will begin accepting TCM (T1017) and PSR (H2017) authorization requests on June 1, 2025.

How to submit Prior Authorization requests

Online: The preferred method is to submit prior auth requests via our Secure Provider Portals:

Fax: Complete and fax the Outpatient Authorization Fax Form (PDF) to the Behavioral Health team at 1-844-208-9113.

Reminder: Use the Pre-Auth Check Tool to check if pre-authorization is needed for any service. 

What provider types does this apply to?

  • Community Behavioral Health Services (05)
  • Specialized Therapeutic Services (07)
  • Residential and Freestanding Psych (16)
  • Social Worker/Case Manager (32)
  • Case Management Agency (91)

What products does this apply to?

  • Sunshine Health Medicaid (MMA)
  • Comprehensive Long Term Care (LTC)
  • Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP)
  • Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI)
  • Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV)
  • Children’s Medical Services (CMS) Health Plan (Including Title 19 and 21)

Frequently Asked Questions: TCM and PSR Services

Effective August 1, 2025, prior authorizations will be required for Targeted Case Management, TCM (T1017) and Psychosocial Rehabilitation, PSR (H2017) services. This change applies to all providers except those who render services to members ages under 4 years of age.

What codes will be impacted?

  • Targeted Case Management: T1017
  • Psychosocial Rehabilitation Services:  H2017

What modifiers are impacted?

  •  T1017 HA and HK are included and will require prior authorization
  •  T1017 TL and SE are not impacted and will not require prior authorization

What provider types will be impacted?

  • Community Behavioral Health Services – (05)
  • Specialized Therapeutic Services – (07)
  • Residential and Freestanding Psych - (16)
  • Social Worker/Case Manager – (32)
  • Case Management Agency – (91)

What products will be impacted?

  • Sunshine Health Medicaid (MMA)
  • Comprehensive Long Term Care (LTC)
  • Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP)
  • Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI)
  •  Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV)
  • Children’s Medical Services (CMS) Health Plan (Including Title 19 and 21)

When must prior authorization be submitted?

Prior authorization for the two services will take effect on August 1, 2025. However, providers can start submitting requests on June 1, 2025.

How to submit prior authorization requests

The preferred method is to submit via our Secure Provider Portals:

Complete and fax the Outpatient Authorization Fax Form (PDF) to the Behavioral Health team at 1-844-208-9113.

What clinical information should be submitted with a prior auth request?

  • Initial assessment
  • Description of service
  • Up-to-date treatment plan
  • Evidence of the member’s participation and progress in the program
  • Up-to-date clinical notes showing evidence of required care

Learn more about correctly submitting Outpatient Treatment Requests (OTR).

What will the Turnaround Time (TAT) be for these requests?

These are considered standard requests and providers should receive a response within five days of submitting the request.

Where can providers find the Outpatient Prior Authorization form?

Download the Outpatient Authorization Fax Form (PDF). This and other provider forms can be found at Manuals, Forms and Resources.

How can providers verify which codes require prior authorization?

Use the Pre-Auth Check Tool to check if pre-authorization is needed for any service.

Who can help providers with questions?

For more information about the services and criteria, please reference these resources:

Questions?

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

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