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Referral and Authorization Information | Ambetter from Sunshine Health
Referral and Authorization Information
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
- Air ambulance transport
- Durable Medical Equipment (DME)
- Home health care services
- Furnished medical supplies
- Genetic testing
- Quantitative urine drug screen
- 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
- 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 from Sunshine Health is a Qualified Health Plan issuer in the Florida Health Insurance Marketplace. Ambetter from Sunshine Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
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