Sunshine Health Prior Authorization Form: Requirements, Submission, and Appeals

A Sunshine Health prior authorization form is submitted through the Secure Provider Portal at provider.sunshinehealth.com, and it must include the member’s ID, the ICD-10 diagnosis code, the CPT or HCPCS procedure code, provider NPIs and tax IDs, and the clinical records that show the service is medically necessary. Without that advance approval for services that require it, Sunshine Health can refuse to pay, leaving the provider or patient on the hook.¹

When a Prior Authorization Is Required

Sunshine Health’s Pre-Auth Check tool lets you enter a specific procedure code to confirm whether approval is needed before you file anything. In broad terms, prior authorization applies to non-emergency inpatient admissions, selected outpatient surgeries, durable medical equipment, home health, hospice, high-tech radiology, and certain behavioral health outpatient services. Any service delivered by an out-of-network provider also requires authorization, with the sole exception of emergency care.²

Common categories that trigger a form:

All non-emergency inpatient stays, including observation, skilled nursing, behavioral health, crisis stabilization, and detoxification.
CT, MRI, MRA, and PET imaging, plus intensity-modulated radiation therapy, proton and neutron beam therapy, and stereotactic radiology.
Bariatric surgery, dental or oral surgery under general anesthesia, cochlear implants, potentially cosmetic procedures such as blepharoplasty and rhinoplasty, and pain management programs.
Durable medical equipment, prosthetics, home infusion, and home health visits after the initial nurse evaluation.
Occupational, physical, and speech therapy after the initial evaluation for members aged 3 and older.
Transplant services from evaluation through follow-up.
Office-administered injectable medications and IV infusion drugs.¹

Emergency room visits and urgent care visits do not need prior authorization, and emergency stabilization at any facility is exempt. Once the member is stabilized, though, the provider has two business days to submit an authorization for ongoing care.³ The first home health nurse evaluation is also exempt; everything after it is not.

What Information the Form Requires

Sunshine Health uses different form templates for different service types. The outpatient Medicaid authorization form and the non-specialty pharmacy form cover most requests. Both are strict about completeness. The outpatient form states plainly that incomplete submissions are rejected.⁴

Member Details

Enter the patient’s Medicaid or Sunshine Health Member ID, date of birth, and legal name. The Member ID is what the plan uses to confirm eligibility. A single transposed digit will bounce the request.

Provider Details

Both the requesting provider and the servicing provider or facility must be listed, each with an NPI, Tax Identification Number, contact name, phone, and fax. The requesting provider’s fax matters: that is where Sunshine Health sends the determination back.⁴

Codes and Service Window

The ICD-10 code describes the condition. The CPT or HCPCS code describes what you want to do about it. The outpatient form has fields for one primary procedure code and up to three additional codes, each with a modifier. You also pick an outpatient service type number and enter a start date, end date, and the total units, visits, or days requested.⁴

Supporting Clinical Records

Attach office visit notes, lab results, imaging reports, and any other records that show why the service is necessary. The outpatient form warns that missing clinical information will delay the determination.⁴

Pharmacy Requests

Prescription requests use a separate form that collects the drug name, strength, dosage form, directions, quantity per day, and length of therapy, along with the patient’s height, weight, allergies, and whether this is a first request or a continuation. A medication history section asks for alternative or previously tried drugs with dates and reasons for discontinuation. Relevant test results, such as HbA1c or genetic testing, should be attached.⁵

How to Submit the Form

Sunshine Health wants medical and behavioral health requests filed through the Secure Provider Portal. The provider manual states that phone or fax submissions for most medical and behavioral health requests will not be processed unless the portal is down or the provider has no internet access.¹ If you are not yet registered, create an account at provider.sunshinehealth.com.⁶

When fax submission is appropriate, use the number that matches the service. Sending a form to the wrong line is one of the easiest ways to lose days.

General outpatient and behavioral health inpatient: 1-866-796-0526
Buy-and-bill drugs: 1-833-823-0001
Transplant requests: 1-833-550-1338
DME and home health (Medicaid): 1-866-534-5978
DME and home health (LTC): 1-855-266-5275
Residential treatment, behavioral health or substance abuse: 1-844-244-9755
LTC home health, wound vacs, and private-duty nursing: 1-844-801-8413⁴¹

Pharmacy prior authorizations go through a different pipeline. Sunshine Health uses Express Scripts for pharmacy claims, and Centene Pharmacy Services handles the PA review. For Medicaid pharmacy, call 1-866-399-0928 or fax 1-833-546-1507. For Children’s Medical Services Health Plan members, call 1-833-705-1351 or fax 1-888-865-6531.⁷

For questions on medical or behavioral health authorizations, Sunshine Health Provider Services is available 24 hours a day at 1-844-477-8313.⁸

When to File and When to Expect a Decision

Non-emergency, pre-scheduled services should be submitted at least five calendar days before the service date. Urgent or emergency inpatient admissions require submission within two business days of the admission. If the request is urgent or expedited, flag it clearly on the cover sheet or in the portal’s priority settings so it enters the faster queue.¹

Federal rules set the outer limits on review time. For rating periods beginning on or after January 1, 2026, a standard authorization decision must be issued within seven calendar days of receiving the request; the earlier 14-day window no longer applies. Sunshine Health can extend that period by up to 14 additional calendar days if the provider or member asks for the extension, or if the plan can show more information is needed and the delay is in the member’s interest.⁹

When a provider indicates that the standard timeframe could seriously jeopardize the member’s life, health, or ability to regain function, the request qualifies for expedited review. Expedited decisions must come within 72 hours. That 72-hour clock can also be extended by up to 14 calendar days under the same conditions.⁹

The portal updates in real time with pending, approved, or denied status and the authorization reference number. Members usually receive a written letter by mail that explains the decision and, if the request is not fully approved, the appeal rights. In urgent cases, Sunshine Health may call the provider’s office directly.

If the Request Is Denied

A denial opens two options, and the right one depends on why the request was turned down.

Peer-to-Peer Review

If the denial turned on clinical judgment rather than missing paperwork, the requesting provider can ask for a peer-to-peer discussion with a Sunshine Health medical director. The request must be submitted within 48 hours of the denial letter date. After that window closes, the only path left is a formal appeal. Peer-to-peer sessions are typically scheduled about two weeks out. Any additional supporting documentation has to be uploaded to the portal before the peer-to-peer request is submitted; documents uploaded afterward will not be reviewed. If the denial was based on missing documentation, a peer-to-peer will not resolve it. Resubmit or appeal instead.¹⁰

Formal Appeal

Members or their representatives can file a formal appeal within 60 calendar days of the denial. Appeals can go in by phone, fax, mail, or email:

Phone: 1-866-796-0530 (TTY 1-800-955-8770)
Fax: 1-866-534-5972
Email: Sunshine_Appeals@centene.com
Mail: Sunshine Health, P.O. Box 459087, Fort Lauderdale, FL 33345-9087

Sunshine Health acknowledges the appeal in writing within five business days and issues a decision within 30 days. For urgent cases, where a member is actively in treatment and a delay could jeopardize their health, or where the issue involves an active inpatient stay, an expedited appeal can be requested verbally or in writing. Expedited decisions come within 48 hours. If Sunshine Health decides the case does not qualify for the fast track, it notifies the member within 24 hours and moves the appeal to the standard 30-day timeline.¹¹

If the denied authorization involved services the member was already receiving, the member can request that those services continue during the appeal. To preserve that right, the appeal and the continuation request must be filed within 10 days of the date on the Notice of Adverse Benefits Determination, or on or before the first day the services would be reduced, suspended, or terminated, whichever is later.¹¹

1
Sunshine Health. Provider Manual
2
Sunshine Health. Florida Medicaid Pre-Authorization
3
Sunshine Health. Crisis Stabilization Unit and Specialty Psychiatric Hospital in Lieu of Services
4
Sunshine Health. Outpatient Medicaid Authorization Form
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Sunshine Health. Prior Authorization Request Form
6
Sunshine Health. Portal for Members – Login
7
Sunshine Health. Medicaid Pharmacy Program
8
Sunshine Health. Contact Us
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eCFR. 42 CFR 438.210 — Coverage and Authorization of Services
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Sunshine Health. Behavior Analysis Peer to Peer Request Form
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Sunshine Health. Complaints, Grievances and Appeals