Over the past several months, Sunflower has announced many changes to its prior authorization (PA) requirements as part of an ongoing effort to reduce provider administrative burden and ease member access to services. Some of these include the following:
- Revised PA requirements for specific codes for physical, occupational and speech therapy.
- No PA requirement for obstetric ultrasounds.
- No PA requirement for bone marrow biopsies when using CPT codes 38220 (Bone Marrow, Aspiration Only) and 38221 (Bone Marrow; Biopsy Needle/Trocar).
- No PA requirement for certain durable medical equipment items.
- No PA requirement for T2046 – hospice long term care, room and board only, per diem and T2042 – hospice routine home care, per diem.
- Revised PA requirements for Long Term Care Nursing Facilities:
- Skilled Care Nursing Facility Services – Prior authorization is required (ventilator, head injury rehabilitation, etc.).
- Custodial Care Nursing Facility Services – Prior authorization will no longer be required.
- New PA requirements for certain medications.
Additionally, to simplify the PA process, KanCare has unified the managed care organization (MCO) and fee-for service forms for medication prior authorizations. The same forms may be used with the three KanCare MCOs and the Fee-For-Service Program. The forms for drugs requiring prior approval for KanCare beneficiaries are located on the KDHE pharmacy webpage.
The changing or removal of prior authorization does not change requirements related to services as outlined in KMAP, provider manuals, or directed by state agencies. Questions about prior authorizations? Please call us or see the prior authorization checker on the Sunflower website.
