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Prior Authorization

Send request to our Utilization Management Department at:

  • Web request: Outpatient Medicaid prior authorization form at sunshinehealth.com
  • Fax: 1-866-796-0526

Sunshine Health must approve in advance the services listed below. Prior approval is required for all services by a provider who is not in the Sunshine Health network. The only exception is for emergency care. Emergency room or urgent care visits do not require prior authorization. This list of services below is not all inclusive. Please call our Provider Services help line at 1-844-477-8313 to check if a prior authorization is required or use our online prior authorization look up tool

Services Requiring Prior Authorization

PCPs, Specialists, or Facilities must request an authorization for the following services. Expand the links below to find out more information.

Post emergency stabilization, if applicable, for all acute and non-acute inpatient facility admissions, including: observations, inpatient hospice, behavioral health, crisis stabilization, detoxification, skilled nursing facility, crisis stabilization and rehabilitation.

Timeframes for notification are:

  • 7 days prior to a scheduled or elective admission
  • Within 48 hours of an emergency admission
  • By next business day for a delivery
  • Air transport
  • Durable Medical Equipment and Prosthetics (list of codes on Sunshine Health’s website)
  • Genetic Testing
  • Home health and home infusion (initial nurse evaluation visit does not require a prior authorization)
  • Home visit by a clinical social worker
  • Occupational, physical, or speech, after the initial evaluation:
    • Members under the age of 21 by HN1, except if service in a PPEC or hospital outpatient, by Sunshine Health
    • Members over the age of 21 by HN1
  • Quantitative Drug Testing for Drugs of Abuse

Note that Early Intervention Services and Targeted Case Management for children age 0 to 3, and medical foster care services do not require an authorization.

  • Notification of Pregnancy (NOP) form within 5 days of member’s first prenatal visit (fax completed NOP to 1-866-681-5125)
  • Doula Services
  • Note: Labor checks do not require a prior authorization if performed in a Sunshine Health participating facility

Any covered potential transplant evaluation, pre-transplant care, transplant and post-transplant follow-up services

  • Adult pneumonia and shingles vaccine for ages 21 to 65
  • Home Delivered Meals - Post-Facility Discharge (Hospital or Nursing Facility)
  • Hospice care
  • Massage therapy
  • Meals provided during non-emergency transportation greater than 100 miles
  • Non-emergency services with a non-participating provider
  • Non-emergency transportation over 100 miles
  • Non-medical non-emergency transportation trips for Child Welfare members
  • Nutritional counseling
  • Observation stays
  • Pain management programs or services
  • Potentially cosmetic or plastic surgery, including but not limited to:
    • Blepharoplasty
    • Breast reconstruction or reduction
    • Varicose vein procedures
    • Septoplasty/rhinoplasty
    • Otoplasty
  • Procedures done in an outpatient hospital setting, ambulatory surgical center or an office, including:
    • Bariatric surgery
    • Dental or oral surgery procedures requiring general anesthesia
  • Implantable devices, including cochlear implants, reprogramming of cochlear Implants and related services
  • Injectable drugs and drugs given by a doctor in an office setting, and IV infusion drugs (list of codes on Sunshine Health’s website)
  • Radiology (by NIA):
    • CT, MRI, MRA, and PET scans
    • Fetal MRI
    • Intensity Modulated Radiation Therapy
    • Proton and Neutron Beam Therapy
    • Stereotactic Radiology
  • Sleep studies performed in a home environment
  • Therapeutic abortions
  • Any potentially cosmetic, experimental or investigational treatments or services, or clinical trials
  • Ambulatory detoxification
  • Art therapy
  • Assessment services
  • Care grants for Child Welfare members
  • Community-based wraparound services
  • Drop in centers
  • Family training and counseling for child development
  • Infant mental health testing
  • Intensive outpatient therapy,
  • Life skills development for Child Welfare members
  • OP individual or therapy, group therapy
  • Partial hospitalization
  • Residential outpatient, for pregnant women with a substance use disorder
  • Self-help peer services
  • Targeted Case Management for those with behavioral health or substance use disorder
  • Transition assistance for Child Welfare members aging out of the foster care system

This list indicates which services require a prior authorization. If a prior authorization isn’t received, the claim for any service noted as requiring a prior authorization will be denied. This is not a complete list of covered services. Limits and services that are not covered are listed in the Member Handbook. Our Utilization Management Department is available Monday through Friday from 8 a.m. to 6 p.m. at 1-866-796-0530, during normal working days. Nurse Advice Line staff are available 24/7 for after-hour calls.

Revised: October 2018

Effective: December 2018