Prior Authorization
Please note, failure to obtain authorization may result in administrative claim denials. Sunflower Health Plan providers are contractually prohibited from holding any member financially liable for any service administratively denied by Sunflower Health Plan for the failure of the provider to obtain timely authorization.
Check to see if a pre-authorization is necessary by using our online tool.
Expand the links below to find out more information.
As the Medical Home, PCPs should coordinate all healthcare services for Sunflower Health Plan members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out-of-network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.
Some services require prior authorization from Sunflower Health Plan in order for reimbursement to be issued to the provider. Use our Prior Authorization Prescreen tool.
Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.
Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.
Using the fax forms located on our Manuals, Forms and Resources page, you may fax requests to:
- Inpatient Fax Form: 1-888-453-4316
- Outpatient Medical Services: 1-888-453-4316
- Concurrent Review – Clinicals: 1-877-213-7732
- Admissions/Face Sheet/Census: 1-866-965-5433
- Home Health and In-Home PT/OT/ST Services: 1-888-453-4316
- Outpatient PT/OT/ST Services: National Imaging Associates (NIA) website or 1-877-644-4623
- Behavioral Health Services: 1-844-824-7705
- High Tech Imaging Services (CT, MRI): National Imaging Associates (NIA)
- Oncology Pharmacy Authorizations: New Century Health
- Musculoskeletal Surgical Services: need to be verified by TurningPoint
Sunflower Health Plan’s Medical Management department hours of operation are De lunes a viernes, de 8 a. m. a 5 p. m. (excluding holidays). After normal business hours, our nurse advice staff is available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admit date.
We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.