Centene prior authorization rules by plan and state

Centene’s prior authorization runs through the plan the patient belongs to: a state Medicaid plan such as Sunshine Health in Florida or Superior HealthPlan in Texas, an Ambetter Health marketplace plan, or a Wellcare Medicare Advantage plan. Each plan publishes its own check for whether a service needs approval, and it decides the request itself or through an outside reviewer.

Medicare Advantage plans must decide an expedited request within 72 hours, and since January 1, 2026 a standard request within 7 calendar days, according to the CMS fact sheet on CMS-0057-F (January 17, 2024). Medicaid managed care plans have the same limits for rating periods that start on or after January 1, 2026. Ambetter plans are outside these limits. Federal claims rules give them up to 15 days for a non-urgent request.

At a glance

• Centene reported 12,518,400 Medicaid members at the end of 2025.
• Ambetter Health is Centene’s marketplace brand, and Wellcare is its Medicare brand.
• Superior HealthPlan has required approval for speech therapy evaluations since August 1, 2026.
• Centene says it honors a previous plan’s approval for 90 days, with conditions.
• Seven Centene plans reported approving 67.06% to 84.91% of standard requests in 2025.

Which Centene plan handles a prior authorization

The patient’s own plan decides the request, or hands it to the outside reviewer it uses for that service. Centene reported these members at December 31, 2025, in its 2025 results release:

Centene offers Medicaid plans in 30 states, according to its Medicaid page. For the rules every Medicaid plan follows, see the guide to Medicaid prior authorization. For Wellcare’s own lists and forms, see the Wellcare prior authorization guide.

How to check whether a Centene plan needs approval

Check the plan the patient is enrolled in. Sunshine Health’s pre-authorization check page (updated October 9, 2026) has separate checks for its Medicaid plans, the Pre-Auth Needed Tool for Ambetter Health members and an Authorization Lookup for Wellcare members. On its MMA, SMI and Child Welfare plans, HN1 reviews physical, occupational and speech therapy after the first evaluation for members aged 3 and older, except in a PPEC, early intervention or hospital outpatient setting. Members aged 0 to 3 need no approval for that therapy.

Superior HealthPlan in Texas has electronic pre-screen tools that show requirements by procedure code, on its prior authorization page. Plans change their lists by dated notice. Superior removed the requirement for certain procedures from January 1, 2026 (notice of December 1, 2025). Since August 1, 2026 it has required approval for speech therapy evaluations for its Medicaid and CHIP members (notice of April 1, 2026).

Each state’s Ambetter plan has its own Pre-Auth Needed Tool. The Florida tool notes that a prior authorization is not a guarantee of payment.

Centene announced on October 13, 2026 that its national gold card program will launch in November 2026, initially for more than 160,000 qualifying providers and select outpatient services. Participation is by invitation, according to Centene’s program page.

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Where Centene plans send therapy, imaging and ABA requests

Several Centene plans send therapy, imaging and post-acute requests to an outside reviewer, and which one depends on the plan and state. Wellcare’s 2026 Medicare Advantage provider manual names Availity Essentials its preferred portal and also takes requests by fax or phone, depending on the service and how urgent it is. For how Availity requests work, see the Availity prior authorization guide. The reviewers named in the plans’ own documents:

For behavior analysis, Sunshine Health requires prior authorization for every service on its Medicaid plans. It decides within 5 calendar days, accepts a request for up to 6 months of services and, since August 1, 2026, has required a PCP acknowledgement form with each new request, according to its behavior analysis resources.

Centene decision deadlines by type of plan

The deadline depends on the type of plan, and some Centene plans set shorter ones of their own.

A Medicaid plan can extend either limit by up to 14 days under 42 CFR 438.210, and a Medicare Advantage plan can extend either by up to 14 calendar days under 42 CFR 422.568 and 422.572. The marketplace limit comes from the federal claims rules, which apply to individual-market plans through 45 CFR 147.136, and can be extended once by 15 days.

Some plans set shorter times. Superior HealthPlan decides a complete routine Texas Medicaid request in 3 business days. Ambetter from WellCare of Kentucky decides a non-urgent request within 5 calendar days of receiving all the information it needs, and no later than 15 calendar days after the request, according to its 2026 provider manual.

Centene’s plans also published their 2025 prior authorization results. The figures below are insurer-reported, as each plan published them, and the reports note that the data may differ from what plans submit to regulators.

In KFF’s review of insurers’ 2025 reports (August 13, 2026), Centene had the highest denial rates of the eight federal-exchange marketplace insurers studied, 25% of standard requests and 23% of expedited ones. Among the six Medicare Advantage insurers, it had the highest share of expedited requests denied, at 13%. When a denial stands, the steps are in the guide to appealing a prior authorization denial.

When a patient joins or switches a Centene plan

Centene says it honors a previous plan’s approval for the same service, under the same benefit type, with an in-network provider, for a 90-day transition period, according to its prior authorization progress update (read October 2026).

Other rules depend on the type of plan. Under 42 CFR 422.112(b)(8), a Medicare Advantage coordinated care plan gives a new enrollee in active treatment a transition period of at least 90 days, even if an out-of-network provider gives the service. Each state sets the Medicaid transition rules, and Sunshine Health gives new Medicaid members up to 120 days of continuity of care, according to its continuity of care page. At Sunshine, moving ABA services to another agency needs a new authorization.

ABS Kids, an ABA provider with more than 5,000 employees, estimates that continuous eligibility monitoring prevents about 90% of the revenue it once lost to Medicaid plan switches, about $150,000 a year. The case study does not name the plans.

How Silna works across Centene’s plans

For a practice with Centene patients, Silna confirms which plan each patient is on and whether the service needs approval under that plan’s rules. It submits the request through the plan’s portal or its outside reviewer and follows up until a decision comes back. It renews approvals ahead of their end dates, and its insurance monitoring flags a patient’s move to a new plan. It works with more than 1,000 payors across 50 states.

Get Silna’s help with your Centene prior authorizations

Key terms

Managed care organization (MCO)

A health plan a state pays to run Medicaid benefits for its members, such as Sunshine Health in Florida.

Ambetter Health

Centene’s marketplace brand, sold under state plan names such as Ambetter from Superior HealthPlan.

Wellcare

Centene’s Medicare brand, including its Medicare Advantage plans.

Pre-Auth Needed Tool

Ambetter’s check for whether a procedure code needs prior authorization.

Gold card program

A program that eases prior authorization review for providers with a strong record, such as Centene’s from November 2026.

Frequently Asked Questions

Does Centene have one prior authorization form?

No. Forms differ by plan. Sunshine Health, for example, lists separate inpatient and outpatient prior authorization forms for its Medicaid plans.

How many days does a Centene plan have to decide?

7 calendar days for a standard request and 72 hours for an expedited one, in Medicare Advantage and in Medicaid managed care for rating periods from January 1, 2026; either plan type can extend by up to 14 days. Ambetter marketplace plans have up to 15 days for a non-urgent request.

How do I check whether a Centene plan needs approval?

Use the tool from the patient’s own plan: Ambetter’s Pre-Auth Needed Tool, Wellcare’s Authorization Lookup, or the Medicaid plan’s own check, such as Superior HealthPlan’s pre-screen tools.

Who reviews therapy requests for Centene plans?

It depends on the plan and state. Evolent reviews physical medicine for Wellcare Medicare Advantage in select states, and physical, occupational and speech therapy for Ambetter from Sunshine Health. HN1 reviews that therapy after the first evaluation for members aged 3 and older on most of Sunshine Health’s Medicaid plans.

Does a Centene plan honor an approval from the patient’s previous plan?

Centene says it does for 90 days, when the approval is for the same service, under the same benefit type and with an in-network provider.

This article is general educational information and does not give medical, legal or insurance advice. Centene’s plans update their lists, tools and forms during the year, so check the patient’s own plan before you send a request.

About the author

Jeffrey Morelli

Jeffrey Morelli is the Co-Founder and CEO of Silna Health, the first Care Readiness Platform built to remove the administrative barriers that delay care. Silna automates benefit checks, eligibility, and prior authorizations across 1,000+ payors, and is backed by $27M from Accel and Bain Capital Ventures. Before Silna, Jeff spent a decade in San Francisco building and scaling products for highly regulated industries, including leading go-to-market at Truework (Series C, acquired by Checkr).

Last updated: October 20, 2026.