Sunshine State Health Plan, Prior Authorization

Sunshine State Health Plan, publishes service-specific prior authorization guidance. Start with the payer resource below, then confirm the member's plan and the requested service before care is scheduled or submitted.

At a glance

• Prior authorization is required for certain services. Sunshine Health directs providers to use the Pre-Auth Check Tool to determine whether a service needs authorization. Official provider pages state authorizations can be submitted through the secure provider portal and, for some workflows, via fax. The provider portal is the preferred/self-service channel for checking eligibility, benefits, claims, authorizations, and referrals.
• Authorization requirements vary by service and line of business.
• Some services have special instructions or effective-date notices (for example, TCM/PSR and CMS ENT changes).
• Do not assume fax is acceptable for all authorization types; the portal is preferred where specified.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2
• Verification resource 3
• Verification resource 4

How to submit prior authorization requests

• Secure Provider Portal

• Fax (for selected authorization workflows/forms)

• Phone for authorization questions / prior auth help line

• Submission resource 1

• Submission resource 2

Information commonly required

• Depends on service and form used; official pages indicate provider identification and member information are generally needed for portal/workflow completion, but a universal required-information list was not found on the official pages reviewed.

Turnaround notes and caveats

• A 24-hour help line is available for prior authorization requests.
• No universal turnaround-time standard for authorization approvals was found on the reviewed official pages; service-specific guidance may apply.
• For some specialized programs, Sunshine Health posts effective-date change notices and directs providers to the portal for submission.
• Authorization requirements vary by service and line of business.
• Some services have special instructions or effective-date notices (for example, TCM/PSR and CMS ENT changes).
• Do not assume fax is acceptable for all authorization types; the portal is preferred where specified.

Provider resources

• Sunshine Health Provider Portal & Resources (official)
• Florida Provider Resources | Florida Medicaid | Sunshine Health (official)
• General Quick Reference Guide for Providers (official)
• Provider Support Guide (official)
• Contact Us (official)
• Provider Complaints (official)

Sources