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Manuals & Forms for Providers | Ambetter from Sunflower Health Plan
Provider Resources
Ambetter Health provides the tools and support you need to deliver the best quality of care.
Please contact us with any questions you may have.
Reference Materials
- 2026 Provider and Billing Manual (PDF)
- 2025 Provider and Billing Manual (PDF)
- Access & Availability Standards (PDF)
- Quick Reference Guide (PDF)
- Pharmacy Guide (PDF)
- Claims, Disputes & Recovery/CCU Guide (PDF)
- ICD-10 Information
- Payspan (PDF)
- Secure Portal (PDF)
- Ambetter Claim Reconsideration and Appeal Quick Reference Guide (PDF)
- Appointment Standards for Scheduling (PDF)
- Interpreter Request Form (PDF)
- Care Management (PDF)
Medical Management
- Pre-Auth Needed?
- Prior Authorization Guide (PDF)
- Oncology Pharmacy Authorizations: For members 18 years of age or older, authorizations for oncology-related chemotherapeutic drugs and supportive agents are administered by Evolent.
- Electroconvulsive Therapy Authorization Form (PDF)
- Inpatient Prior Authorization Fax Form (PDF)
- Intensive Outpatient/Day Treatment Authorization Form (PDF)
- Outpatient Prior Authorization Fax Form (PDF)
- Outpatient Prior Authorization Supplemental Form (PDF) - This is an optional page meant to be used in conjunction with the Sunflower's Outpatient Prior Authorization Request form when a request exceeds more than four procedure codes. This page should never be submitted alone.
- Outpatient Treatment Request Form (PDF)
- Provider Fax Back Form (PDF)
- Applied Behavioral Analysis Authorization Form (PDF)
- Birth Event Notification (PDF): Optional form to report birth events/outcomes.
- Neuropsychological Testing Authorization Request Form (PDF)
- Transcranial Magnetic Stimulation (TMS) Request Form (PDF)
- Behavioral Health Outpatient Psychological Testing Request Form (PDF)
- Non-Formulary And Step Therapy Exception Request Form (PDF)
- Medical Necessity Criteria
- Discharge Planner Checklist (PDF)
Claims and Claims Payment
- Provider Request for Reconsideration and Claim Dispute Form (PDF)
- No Surprises Act Open Negotiation Form (PDF)
Quality
- Quality Improvement (QI)
- Practice Guidelines (PDF)
- Providing Quality Care
- Quality Rating System (QRS) Behavioral Health Measure Toolkit (PDF)
Other
CMS Interoperability & Prior Authorization Final Rule: CY2025 Prior Authorization Requirements Reports and Metrics Summaries
In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.
Reports:
- Ambetter from Sunflower Health CMS Final Rule 0057-F Prior Authorization Requirements: 34368 (PDF)
- Ambetter from Sunflower Health Prior Authorization Metrics Summary: 34368 (PDF)
The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.