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Pre-Auth Needed? | Ambetter de Sunshine Health
For the best experience, please use the Pre-Auth tool in Chrome, Firefox, or Internet Explorer 10 and above.
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.
Outpatient Physical Therapy, Occupational Therapy, Speech Therapy needs to be verified through NIA
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
Complex imaging, MRA, MRI, PET, and CT Scans need to be verified by NIA
Musculoskeletal, Cardiac and ENT services need to be verified by Turning Point Fax: 954-622-8034
Oncology/supportive drugs for members age 18 and older need to be verified by New Century 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
Speech, Occupational and Physical Therapy need to be verified by NIA. 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 services for HMO members being performed or ordered by a non-participating provider?|
|Is the member being admitted to an inpatient facility?|
|Are anesthesia services being rendered for pain management or dental surgeries?|
|Is the member receiving hospice services?|