Referral and Authorization Information | Ambetter from Sunshine Health

 

Referral and Authorization Information

Ambetter Bronze, Silver, and Gold Plans

Referrals

If you have a specific medical problem, condition, injury or disease, you may need to see a specialist.  A specialist is a provider who is trained in a specific area of healthcare. Talk to your Primary Care Provider (PCP) first. He/she will refer you to a specialist for care if necessary. Do not go to a specialist without being referred by your PCP. The specialist may not see you without this referral.

It is also important you verify the specialist you are referred to is in the Ambetter from Sunshine Health network, so you don’t get billed for something you weren’t expecting.

Please note, there are some services that you may go directly to a specialist for without a referral. For example, you do not need a referral from your PCP for treatment from an in-network obstetrician or gynecologist. For a full listing of these services, please refer to your Evidence of Coverage - you can find it on your online member account at Ambetter.SunshineHealth.com. 

If you need care that your PCP cannot provide, he/she can recommend a specialist provider. Paper referrals are not required.

The following are services that may require a referral from your PCP:

  • Specialist services, including standing or ongoing referrals to a specific provider
  • Diagnostic tests (X-ray and lab)
  • High tech imaging (CT scans, MRIs, PET scans, etc.)*
  • Planned inpatient admission*
  • Clinic services
  • Renal dialysis (kidney disease)*
  • Durable Medical Equipment (DME)*
  • Home healthcare*

*Services above marked with an asterisk require prior authorization through Ambetter from Sunshine Health before receiving the service.

Prior Authorization for Services

Sometimes, we need to approve medical services before you receive them. This process is known as prior authorization. Prior authorization means that we have pre-approved a medical service.

To see if a service requires authorization, check with your Primary Care Provider (PCP), the ordering provider or Member Services. When we receive your prior authorization request, our nurses and doctors will review it.  We will let you and your doctor know if the service is approved or denied.

Information about the review process, including the timeframes for making a decision and notifying you and your provider of the decision, is located in the Utilization Review section of your Member Handbook.

Failure to obtain prior authorization may result in a denied claim(s). To see a full listing of procedures and services that require PRIOR AUTHORIZATION, please log in to your secure member account to view your Schedule of Benefits.

The following services require the member’s provider to contact Ambetter from Sunshine Health for prior approval:

THE FOLLOWING LIST IS NOT ALL-INCLUSIVE

Ancillary Services

  • Air ambulance transport 
  • Durable Medical Equipment (DME)
  • Home health care services
  • Hospice
  • Furnished medical supplies
  • Orthotics/prosthetics
  • Genetic testing
  • Quantitative urine drug screen

Procedures/Services

  • Reconstructive Surgery
  • Experimental or investigational
  • High Tech Imaging administered by NIA (CT, MRI, PET)
    • Submit requests to RadMD.com
  • Pain management
  • Cardiac and respiratory therapy

Inpatient Admissions

  • All inpatient admissions (within 1 business day of admission)
  • Observation stays exceeding 48 hours
    • Notification is required within one (1) business day if admitted
  • Transplants (not including evaluations
  • Urgent/emergent admissions
  • Partial inpatient, PRTF, and/or intensive outpatient programs
  • All elective/scheduled admission notifications requested at least five (5) days prior to the scheduled date of admit including but not limited to:
    • Medical admissions
    • Surgical admissions
    • Hospice care
    • Rehabilitation facilities

Out-of-Network Services: All out-of-network services and providers require prior authorization, excluding emergency services.


You can also call your PCP or Ambetter from Sunshine Health Member Services with questions.

All out-of-network services require prior authorization, excluding emergency room (ER) services.

Ambetter Value Plan

Your Ambetter Value plan requires a referral from your Primary Care Provider (PCP) before you can see most specialists. Your claim will not be covered without a referral.

Here’s what you need to do:

1. Select Your PCP

If you haven’t already, select a PCP. You can view a list of recommended PCPs and select your PCP on Find a Doc.

2. Meet With Your PCP

Your PCP will help coordinate all your health care services and provide any necessary referrals. During your PCP visit you should discuss your goals, follow up with your Care Team, and obtain any necessary referrals.

Important!

  • If you have an appointment already scheduled with a specialist, you will need to contact your PCP first. You will need to obtain a referral prior to the specialist visit.
  • If you do not have a referral from your PCP, your specialist visit will not be covered. The claim will be denied, and it won’t be paid.

3. Schedule specialist visit

Members can see any in-network specialist with a referral.

Referrals are NOT required for the following services:

  • Emergency services
  • Urgent care services
  • Mental health, behavioral health, and substance abuse services
  • Obstetrical and gynecological care

Referral FAQs

Medical referrals are required to see a specialist if it's outside of the Primary Care Physicians' scope. Members must obtain a referral before consulting with an in-network specialist if they are a Value plan member. 

Only your PCP may provide a referral for specialist care.

The claim will be denied.

No. Your PCP will need to submit a new referral if they determine additional specialist care is necessary.

No. If treatment is needed that may require Prior Authorization, the provider/specialist will need to follow the Prior Authorization process. 

If the specialist feels that additional visits are needed beyond those requested by your PCP, a new referral will need to be submitted by your PCP. 

You can seek a second opinion with another PCP in your Primary Provider Group.

Please allow seven (7) to ten (10) business days for the referral to be loaded on the member secure portal. You will then be able to view and print any referrals from your secure portal. You can also request a copy from your PCP. 

If you are looking for a referral for a service that is not ‘on file' or in the system, this means your PCP has not submitted the referral. You will need to check with your PCP to ask for the referral to be submitted.

The following specialties do not require referral from your PCP. Services performed by these specialists may still require prior authorization.

  • Urgent Care
  • Emergency Care
  • OBGYN
  • Radiology/Imaging
  • Anesthesia
  • Mental Health
  • Behavioral Health
  • Substance Abuse Services
  • Labs

Ambetter Virtual Access Plan

Your Ambetter Virtual Access plan requires a referral from your Primary Care Provider (PCP) before you can see most specialists. Your claim will not be covered without a referral. 

Here’s what you need to do:

1. Create Your Online Member Account

If you haven’t already, set up your online member account at ava.teladoc.com. This is the best way to manage your health insurance and get the most out of your coverage.

2. Click on “Virtual Access” or “Telehealth Connect Now” to Select Your PCP (Primary Care Physician)

Select a Teladoc Virtual Primary Care Physician (PCP) and schedule your first wellness appointment. Your PCP will help coordinate all your health care services.

Important!

  • To see a specialist, you must obtain a referral from your Teladoc Virtual PCP.
  • If you have an appointment already scheduled with a specialist, you will need to schedule a visit with your new Teladoc Virtual PCP through the Ambetter Virtual Access Member app. You will need to obtain a referral prior to the specialist visit.
  • It’s easy to confirm referrals made by your PCP through the Ambetter Virtual Access Member app. If you do not have a referral from your PCP, your specialist visit will not be covered. The claim will be denied, and it won’t be paid.

Referrals are NOT required for the following services:

  • Emergency services
  • Urgent care services
  • Mental health, behavioral health, and substance abuse services
  • Obstetrical and gynecological care

3. Meet With Your PCP

Meet with your Teladoc Virtual PCP by video or phone. Discuss your goals, follow up with your Care Team, and obtain any necessary referrals.

4. Review Your Benefits

Other Teladoc virtual services include Urgent Care, Mental Health, Dermatology, and Nutrition. Log in to your Ambetter Virtual Access account to see what other health benefits are included through your health plan.

Referral FAQs

Medical referrals are required to see a specialist if it's outside of the Primary Care Physicians' scope. Members must obtain a referral before consulting with an in-network specialist if they are a Value or Virtual plan member. 

Your chosen PCP is required to refer you to a specialist when medical care is needed beyond their scope of treatment. 

If a claim is submitted without referral or prior authorization, it will be denied.

Talk to your PCP about options. Or call member services.

No, all specialists must coordinate with your PCP. Your PCP will need to submit a new referral for additional specialists. 

No, a referral is only valid for the consultation. If treatment is needed that may require Prior Authorization, the provider/specialist will need to follow the Prior Authorization process. 

No, if the PCP is submitting a Prior Authorization, the referral will not be required. However, if a specialist is submitting a Prior Authorization, the specialist must coordinate with your PCP for a referral request.

If the specialist feels that additional visits are needed beyond those requested by your PCP, a new referral will need to be submitted by your PCP. 

You can seek a second opinion with another PCP in your Primary Provider Group.

  • Please allow seven (7) to ten (10) business days for the referral to be loaded on the member secure portal. You will then be able to view and print any referrals from your secure portal.
  • You can also request a copy from your PCP. 

     

If you are looking for a referral for a service that is not ‘on file' or in the system, this means your PCP has not submitted the referral. You will need to check with your PCP to ask for the referral to be submitted.

  • Consult your Teladoc PCP, who can refer you to a medically appropriate site of care
  • Visit an in-network Urgent Care center for an in-person visit without a referral

Yes, but you give up the benefit of $0 virtual PCP visits via Teladoc. You will also be responsible for the cost of in person PCP visits. The referral requirement still applies, regardless of your PCP.

Yes, $0 virtual visits apply only to Teladoc

No, ID cards do not reflect a PCP, so you have access to both virtual and Ambetter Core providers. Therefore, a new ID card isn’t necessary. The copay will remain the same.

 

Ambetter from Sunshine Health includes EPO products that are underwritten by Celtic Insurance Company, and HMO products that are underwritten by Sunshine State Health Plan, Inc., which are Qualified Health Plan issuers in the Health Insurance Marketplace. This is a solicitation for insurance. © 2023 Sunshine State Health Plan, Inc. All rights reserved.