Pre-Auth Needed? | Ambetter de Sunshine Health


Pre-Auth Needed?

For the best experience, please use the Pre-Auth tool in Chrome, Firefox, or Internet Explorer 10 and above. 

DISCLAIMER: Your current browser's security settings does not allow the use of this tool. This tool requires the use of Internet Explorer 10 or Later. If you are currently using Internet Explorer as your browser and you see this message, you should try to update it or use another browser like Google Chrome or Firefox.

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.

The following services (identifiable by procedure code search) need to be verified by Evolent: Cardiac Imaging, Complex Imaging, MRA, MRI, PET, and CT scans; Speech, Occupational and Physical Therapy (excluding chiropractor specialty providers – no authorization required); Effective for dates of service 1/1/2024 forward, Musculoskeletal services for the spine, shoulder, hip and knee.

Cardiac and Ear, Nose and Throat (ENT) procedures need to be verified by TurningPoint.  Musculoskeletal services for DOS prior to 1/1/2024 will continue to be verified by TurningPoint.

Vision services, including all services rendered by an Optician, Ophthalmologist, or Optometrist need to be verified by Envolve Vision

Dental services need to be verified by Envolve Dental

Behavioral Health/Substance Abuse need to be verified by Sunshine Health

Oncology Biopharmacy, Radiation Oncology drugs, and administration of Radiation Oncology need to be verified by Evolent.

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

For Chiropractic providers, no authorization is required.


Services provided by Out-of-Network providers are not covered by the plan. 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 Reassignment services?