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Authorization Not Required for Coordination of Benefits

Date: 04/01/21

Sunflower Health Plan does not require authorization for inpatient admission or outpatient services in order for Coordination of Benefits (COB) to occur on claims where another health insurance carrier is the primary payer. As such, Sunflower will not create an authorization number when it is identified that Sunflower is the secondary payer for a service. This does not apply to PRTF (Psychiatric Residential Treatment Facilities), as an authorization is required for this service regardless of existence of a primary insurance coverage.

  • As a reminder, Sunflower will not coordinate benefits when the primary insurer denies for the following reasons:
    • No authorization/lack of medical necessity
    • Untimely filing
    • Duplicate denial
  • Sunflower identifies primary payer based on the member’s eligibility information in KMAP.
    • If you have information indicating that a primary insurance coverage has been terminated despite KMAP indicating that a non-Medicaid primary coverage exists, please submit an authorization request indicating “primary coverage terminated on xx/xx/xx.” Please also notify KMAP of the primary coverage termination via the Beneficiary TPL Insurance Information Update form (PDF).

Situations which still require authorization:

  • PRIMARY PAYER DENIAL: If the primary insurer denies due to lack of benefits, the provider will be required to obtain an authorization for any service for which Sunflower requires authorization for reimbursement when Sunflower is the primary payer. The provider is encouraged to obtain an authorization for the following potential primary payer denials:
    • Non-covered service
    • Benefits exhausted

Please submit evidence of primary payer denial with the request for authorization. Sunflower will treat these requests as Sunflower primary and review accordingly.

  • MEDICARE: If the member has only Medicare B/D, but not Medicare Part A, Sunflower is the primary payer for inpatient care. Thus, an authorization will be required for inpatient admission.
  • NEWBORNS: For NICU admissions and extended newborn stays (longer than 48 hours following vaginal delivery or 96 hours following C-Section delivery), please request authorization, even if the mother has a primary payer other than Sunflower.
  • PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES: Authorization is required for all PRTF requests regardless of the existence of a primary insurance coverage.

Prior authorization request or notification of admission must be completed in a timely manner, in accordance with the Sunflower Provider Manual.

If you have questions about this bulletin or other provider resources, please call Customer Service at 1-877-644-4623.