Vendor Affiliates
Our vendor affiliates manage vision, dental, pharmacy, transportation, OT/PT/ST and radiology benefits.
AMBETTER: Oncology & supportive medications for members age 18 and older need to be verified by New Century Health.
SUNFLOWER MEDICAID: Beginning May 10, 2021, Oncology & supportive medications for members age 21 and older need to be verified by New Century Health.
Sunflower Health Plan has contracted with National Imaging Associates Inc. (NIA), an affiliate of Magellan Health Services, for radiology benefit management.
The program includes management of non-emergent, high-tech, outpatient radiology services through prior authorization. This program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.
Sunflower Health Plan oversees the NIA program and is responsible for claims adjudication. NIA manages non-emergent outpatient imaging/radiology services through contractual relationships with free-standing facilities.
Prior authorization is required for the following outpatient radiology procedures:
- CT/CTA/CCTA
- MRI/MRA
- PET Scan
KEY PROVISION:
Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim.
Go to the NIA website for more information.
Effective June 1, 2020, outpatient physical medicine services (physical therapy, occupational therapy and speech therapy) are no longer managed through a post-service review process for Sunflower Health Plan
- PRIOR AUTHORIZATION REQUIRED: Sunflower remains committed to ensuring that physical medicine services provided to our members are consistent with nationally recognized clinical guidelines. Therefore, beginning June 1, 2020, prior authorization of outpatient physical medicine services will be required for Sunflower Health Plan membership. The utilization management of these services will continue to be managed by NIA.
- Under terms of the agreement between Sunflower Health Plan and NIA, Sunflower will oversee the NIA Physical Medicine Prior Authorization program and continue to be responsible for claims adjudication.
- Providers can obtain prior authorization via the NIA website or 1-877-644-4623.
- Please ensure that the member has not exhausted his/her benefit prior to providing services, even if an “Approved Authorization” has been obtained. The purpose of NIA is to verify medical necessity of physical medicine services, and not to manage the member’s benefits.
See Sunflower Bulletin SHPBN-2020-035 or the Sunflower page on NIA's website for more details.
Beginning January 1, 2021, NIA will provide utilization management for outpatient rehabilitative and habilitative physical medicine services on behalf of Ambetter from Sunflower Health Plan membership in Kansas.
Musculoskeletal surgical services need to be verified by TurningPoint.