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Prior Authorization

How to Reach Prior Authorization Staff with an Authorization Request

When you need care, always start with a call to your PCP. Some covered services may need prior approval. They may need review by Sunshine Health before services are given. This includes services or visits to an out-of-network provider. Hospital stays, transplants, home health services, some surgeries, medical equipment and some medicines require prior approval. Your doctor can tell you if a service needs a prior approval. The list of these services can be found below.

You can also call Member Services if you have questions. The number is 1-866-796-0530.

Some covered services require a prior authorization from Sunshine Health before the service is provided. The list of services that need a prior authorization can include an admission to the hospital after your emergency condition has improved, power wheelchairs, home health visits, MRI X-rays, hospice care, genetic testing, pain management or some outpatient surgery. That list is on our website at SunshineHealth.com. Your PCP or other doctor that is treating you can request an authorization from Sunshine Health. When your doctor requests an authorization, he or she must send information about your health condition and treatment. This may include copies of your medical record, results of tests, what medications you have tried, or what kind of support you need to take care of yourself at home. You can go to any participating Sunshine Health doctor for covered services.

Your doctor will give us information about why you need the service. Sunshine Health will look to see if the service is covered and that it is necessary. Sunshine Health will make the decision as soon as possible, based on your medical condition. Standard decisions are made within seven calendar days. If the service is urgent, the decision will be made within 48 hours. We will let you and your doctor know if the service is approved or denied. If you or your doctor is not happy with the decision, you can ask for a second review. This is called an appeal. See the “Member Satisfaction” section in your Member Handbook. This will give you more information about appeals.

If there are any major changes to the prior authorization process, we will let you and your doctors know right away.

Prior Authorization List

Sunshine Health needs to 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.

Services Requiring Prior Authorization

PCPs, Specialists, or Facilities must request an authorization for the following services:

All acute and non-acute inpatient facility admissions, including: observations, inpatient hospice, behavioral health, 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, speech, or respiratory therapy:
    • 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

  • 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

  • Hospice care
  • Pain management programs or services
  • 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
  • Medical foster care services

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
  • Potentially cosmetic or plastic surgery, including but not limited to:
    • Blepharoplasty
    • Breast reconstruction or reduction
    • Varicose vein procedures
    • Septoplasty/rhinoplasty
    • Otoplasty
  • Therapeutic abortions
  • Nutritional counseling

  • Adult pneumonia and shingles vaccine for ages 21 to 65
  • Any potentially cosmetic, experimental or investigational treatments or services, or clinical trials
  • Behavioral health or substance abuse services including ambulatory detoxification, partial hospitalization, self-help peer services, OP therapy, group therapy, intensive outpatient therapy, infant mental health testing and Targeted Case Management
  • Behavioral Health - Art Therapy
  • Food and lodging for family of member admitted over 150 miles from home for specialty care
  • Injectable drugs and drugs given by a doctor in an office setting, and IV infusion drugs (list of codes on Sunshine Health’s website)
  • Non-emergency services with a non-participating provider
  • Home Delivered Meals - Post-Facility Discharge (Hospital or Nursing Facility)
  • Meals provided during non-emergency transportation greater than 100 miles
  • Massage Therapy
  • Acupuncture

This list indicates what services require a prior authorization. If there is no prior authorization received from Sunshine Health, the claim for any service noted as needing 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. The 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.