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Sunshine Health Updates Medicaid Prior Authorization (PA) Requirement Changes Effective September 1, 2024

Date: 08/21/24

Sunshine Health has updated the list of Medicaid Prior Authorization changes that will take effect September 1, 2024.

We will no longer implement the Behavioral Health codes we previously shared with you in July. Sunshine Health will re-evaluate those codes and share an update with you in the upcoming months.

The physical health codes remain the same and will still take effect on September 1, 2024.

Sunshine Health requires prior authorization as a condition of payment for many services. This notice contains information regarding such prior authorization requirements and is applicable to all Medicaid products offered by Sunshine Health.

Here is the updated list of Medicaid Prior Authorization Changes (PDF) that will take effect September 1, 2024.

Sunshine Health is committed to delivering cost-effective, quality care to our members. This requires us to ensure that our members only receive treatments that are medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Please verify every member’s eligibility and benefits prior to rendering services to them. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. Non-Par Providers and facilities require authorization for all HMO services except where indicated.       

The codes included in the PDF document represent the national, standard code sets. Inclusion or exclusion of a code does not constitute or imply subscriber coverage or provider reimbursement. Please refer to your contract with Sunshine Health to determine all contracted/covered codes for each membership group. Please refer to the Medicaid Fee Schedule and the Billing and Procedure Coding Guide for a list of approved modifier codes.

For a complete list of CPT/HCPCS codes, please use the Pre-Auth Check Tool.

Questions?

If you have any questions, please call Sunshine Health Provider Services at 1-844-477-8313 or visit the Secure Provider Portal. Our Provider Engagement staff are also here to help answer questions. Visit the Find Your Administrator tool to confirm the individual supporting your specialty and region. We encourage you stay up to date on Sunshine Health provider notices by reviewing and bookmarking Provider News.

 

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