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Pre-Auth Tool | Ambetter from Sunshine Health
Pre-Auth Needed?
/content/ambetter-fl/en_us/provider-resources/manuals-and-forms/pre-auth
DISCLAIMER:
All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.All attempts are made to provide the most current information on the Pre-Auth Needed Tool. A prior authorization is NOT a guarantee of payment. Claim payment depends on member eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
Vision services need to be verified by Centene Vision ServicesExternal Link.
Dental services need to be verified by Centene Dental ServicesExternal Link.
The following services need to be verified by EvolentExternal Link: Speech, occupational & physical therapy; Complex Imaging, MRA, MRI, PET & CT scans; Musculoskeletal services for shoulder, hip, spine and knee surgery; Chiropractic specialty providers are NOT managed by Evolent.
The following services need to be verified by EvolentExternal Link: Medical and Radiation Oncology / Biopharmacy drugs. Effective for dates of service 4/1/2025 forward, Cardiac surgical procedures for members ages 19 and older.
Cardiac procedures need to be verified by TurningPointExternal Link for dates of service through 3/31/2025. Ear, Nose and Throat (ENT) procedures need to be verified by TurningPointExternal Link for dates of service through 4/30/2025.
Behavioral Health/Substance Abuse services need to be verified by Sunshine Health.
Drug authorizations need to be verified by Envolve Pharmacy Solutions. For assistance call 866-399-0928.
Post-acute facility (SNF, IRF, and LTAC) prior authorizations need to be verified by CareCentrix; Fax 877-250-5290
Discharge ONLY DME/ Home Health Fax 833-422-1462
Services provided by Out-of-Network providers are not covered by the plan, without prior authorization. Join Our Network
Note: Services related to an authorization denial will result in denial of all associated claims.
Are Services being performed in the Emergency Department?
| Types of Services | YES | NO |
|---|---|---|
| Are the services being performed or ordered by a non-participating provider (professionals/facilities)? | ||
| Is the member being admitted to an inpatient facility? | ||
| Are anesthesia services being rendered for dental surgeries? | ||
| Are oral surgery services being provided in the office? | ||
| Is the member receiving Gender Affirming services? |