Prior Authorizations and Referrals
Prior Authorization and Referrals
Some medical services, behavioral-health services, Home and Community Based Services (HCBS) or medications may need approval, and this is called a prior authorization. You do not need a paper referral from Sunflower Health Plan to see a provider, but your provider may need to request a prior authorization from Sunflower for a service to be approved. Prior authorization should be requested before the scheduled service date or as soon as the need for the service is identified, including weekdays, weekends and holidays. Standard requests have a turnaround time of 14 calendar days. Urgent requests have a turnaround time of 72 hours.
Failure to prior authorize services that require Sunflower authorization may result in a denial of the claim for the service. Authorization is not required for services for which Sunflower is the secondary or tertiary insurance.
Medical and Behavioral Health Care Services
When you need health care, always start with a call to your medical or behavioral-health provider. You don’t need a referral from your primary care provider (PCP). As part of your Kansas Medicaid benefits and coverage, Sunflower can help you find a provider, find local resources, plan an appointment and find transportation. Call Customer Service at 1-877-644-4623 (TTY: 711).
Pre-scheduled, optional services must be approved by Sunflower Health Plan before you are admitted. Your provider will send a request to Sunflower. Emergent admissions (emergency room/department) require prior authorization from the hospital up to one business day after admission for timely notification.
- How soon can I expect to be seen by a specialist? In some situations, the specialist may see you right away. Please refer to the Appointment Availability and Wait Times page.
- How do I ask for a second opinion? You have the right to a second opinion from a Sunflower Health Plan provider if you are not satisfied with the plan of care offered by the specialist. Your primary care healthcare provider should be able to give you the name of a provider for a second opinion visit. If your primary care provider wants you to see a specialist that is not a Sunflower Health Plan provider, that visit will have to be approved in advance by Sunflower.
- Non-Participating/Out-of-Network Providers Requests for services from a provider, facility or vendor that is not in the Sunflower Health Plan network need to be approved by getting a prior authorization.
Your healthcare provider can tell you if a medical service or prescription needs prior authorization. The list below gives you general categories of services requiring prior authorization. Please keep in mind that services and benefits change from time to time. This prior authorization list is for your general information only. Please call Sunflower Customer Service at 1-877-644-4623 (TTY 711) for the most up-to-date information.
Below is a list of services that require prior authorization from Sunflower before your healthcare provider can proceed with treatment. Please note this is not a complete list. Check with your provider to ensure authorization requirements are considered.
|Services That Require a Prior Authorization||Prior Authorization Required for Some or All of the Services?|
|Ambulatory Surgery Center||Some services require prior authorization.|
|Bariatric Surgery (Certain restrictions and limitations may apply)||Yes|
|Durable Medical Equipment (DME)||Some items require prior authorization.|
|Experimental or Investigational Services (E.g., Clinical Trials)||Yes|
|Home Health Care Services||Yes|
|Hospice Care||Some services require prior authorization.|
|Hospital Services Inpatient||Yes. All services performed in out-of-network facility are required|
|Hospital Services Outpatient||Some services require prior authorization. All services performed in out-of-network facility are required|
|Inpatient Services (E.g., Skilled Nursing Facility, Long Term Acute Care and Rehabilitation)||Yes|
|Laboratory Services: All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health.||Some services require prior authorization.|
|Maternity Services||Some services require prior authorization.|
|Medical Services Clinic||Yes|
|Medications||Some medications require prior authorization. Sunflower uses the KanCare Preferred Drug List|
|Orthotics & Prosthetics (O&P): Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body.||Some services require prior authorization.|
|Oxygen & Respiratory Services||Some services require prior authorization.|
|Substance Use Disorder Services||Some services require prior authorization.|
|Therapy (OT, PT, ST) Services (Outpatient)||Yes. Services are provided through Sunflower-approved vendor NIA.|
All such services determined by Kansas Medicaid to be medically necessary shall constitute a Sunflower Health Plan covered service. See the Sunflower Health Plan Member Handbook for more information on benefits and covered services, coverage out of network and out of the Sunflower Health Plan service area.