Provider Toolkit: Prior Authorization Guide

How to Secure Prior Authorization

Pre-Auth Needed Tool

Use the Pre-Auth Needed Tool on Ambetter.SunshineHealth.com to quickly determine if a service or procedure requires prior authorization.

Submit Prior Authorization

If a service requires authorization, submit via one of the following ways:


SECURE WEB PORTAL
provider.sunshinehealth.com
This is the preferred and fastest method.


PHONE
1-877-687-1169
After normal business hours and on holidays, calls are directed to the plan’s 24-hour nurse advice line. Notification of authorization will be returned by phone, fax or web.


FAX
Medical
1-855-678-6981

Behavioral Health
1-844-208-9113

Discharge ONLY DME/Home Health
833-422-1462

See below for a list of services that require prior authorization.

Please note:

  1. Emergency services DO NOT require prior authorization.
  2. All out-of-network services and providers DO require prior authorization.
  3. Failure to complete the required authorization or notification may result in a denied claim.

Services and Procedures Requiring Prior Authorization

THE FOLLOWING LIST IS NOT ALL-INCLUSIVE

Ancillary Services

Procedures/Services

Inpatient Admissions

  • Air ambulance transport (non-emergent fixed wing airplane)
  • Durable Medical Equipment (DME)
  • Home healthcare services
  • Hospice
  • Furnished medical supplies
  • Orthotics/prosthetics
  • Genetic testing
  • Quantitative urine drug screen
  • Reconstructive surgery
  • Experimental or investigational
  • High Tech Imaging administered by NIA (CT, MRI, PET):
    • Submit requests to RadMD.com
  • Pain management
  • Cardiac and respiratory therapy
  • All inpatient admissions (within 1 business day of admission)
  • Observation stays exceeding 48 hours 
    • Notification is required within 1 business day if admitted
  • Transplants (not including evaluations)
  • Urgent/emergent admissions
  • Partial inpatient, PRTF and/or intensive outpatient programs

All elective/scheduled admission notifications requested at least 5 days prior to the scheduled date of admit including but not limited to:

  • Medical admissions
  • Surgical admissions
  • Hospice care
  • Rehabilitation facilities


LOG INTO OUR SECURE WEB PORTAL

provider.sunshinehealth.com