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Referral and Preauthorization Requirements

Fecha: 26/09/25

 Message for All Sunflower Providers. Please share with your administrative team.

Sunflower Health Plan is committed to supporting members with access to high-quality, cost-effective care. This includes ensuring that referrals and services—particularly those involving out-of-state, out-of-network providers—are coordinated and compliant with the Participating Provider Agreement.

Providers are required to comply with all referral and preauthorization procedures adopted by Sunflower Health Plan or the applicable payer before referring a Covered Person to any provider or facility.

Referral Pathways:

  • Providers must refer members to in-network participating providers whenever available. Referrals to out-of-network or out-of-state providers should only occur when an in-network option close to the member’s community cannot meet the member’s medical needs.

Preauthorization:

  • All out-of-network referrals and services require prior authorization. Providers must submit the appropriate authorization request through the Sunflower Provider Portal or by calling Provider Services at one of the phone numbers below. For authorization timeframes, please refer to the provider manual for each line of business.

Emergency Services:

  • Emergency care may be provided without prior authorization; however, notification to Sunflower Health Plan must occur as outlined in your provider manual.

Compliance:

  • Failure to follow referral and preauthorization procedures may result in denial of payment for unauthorized services.

Important Notes

  • These requirements are designed to ensure members receive high-quality care while managing costs responsibly.
  • Coordinating care through the network helps with accurate claims processing and supports continuity of care.
  • Providers are encouraged to verify member eligibility and benefits prior to initiating any out-of-network referrals.

If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative or call us at the numbers below: