Adult Primary Care Physicians (PCP) Quick Reference Guide

Important Contact Information

Provider Services
- All products
- 1-844-477-8313
- Monday-Friday from 8 a.m. to 8 p.m. Eastern
Pharmacy Services
- All products
- 1-800-460-8988, option 2
- 24 hours a day, 7 days a week
Member Services
- CMS
- 1-866-799-5321
- Monday-Friday from 8 a.m. to 8 p.m. Eastern
Member Services
- MMA, SMI, LTC
- 1-866-796-0530
- Monday-Friday from 8 a.m. to 8 p.m. Eastern

Verifying Member Eligibility

These suggestions are not a guarantee of coverage.

Verify member eligibility by using the Sunshine Health Secure Provider Portal.
Using the portal, any registered provider is able to quickly check member eligibility by indicating the date of service, member name and date of birth or the Medicaid ID number and date of birth.
- Ensure you’re selecting the correct plan type.
Alternatively, you can call Provider Services at 1-844-477-8313. Supply the member’s name and date of birth or the member’s Medicaid identification number and date of birth.

Authorizations

Prior authorization is required for certain services. To determine which services require authorization, please refer to our Pre-Auth Check Tool.

Prior-authorization requests are processed by Sunshine Health’s Utilization Management (UM) Department.

Standard requests: Determination within 7 calendar days of receipt of request.
Urgent requests: Please call 1-844-477-8313. Urgent requests are made when the member or his/her physician believes that waiting for a decision under the standard timeframe could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.

Submit authorization requests via one of the following:

Online: via the Sunshine Health Secure Provider Portal
Telephonically: 1-844-477-8313
Medical Fax: 1-866-796-0526
Pharmacy Services Fax: 1-833-546-1507

Note: Find the Treatment/Service Request Forms for fax submission online.

Claims

Covered Services

Preventative Healthcare Services
Hearing Services
Laboratory Services
Radiology Services
Child Health Check-Ups
Dental Services

For more information regarding covered services refer to AHCA at Primary and Preventive Care Policy.

Description of the Specialty: Primary Care Practitioners are defined as a Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), Physician Assistant (PA) who is certified in one of the following specialties: internal medicine, general medicine, geriatric medicine, family medicine, and or hospice and palliative medicine.

Billing: The following codes are included below for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply subscriber coverage or provider reimbursement. The codes listed below are not a complete list. Please refer to your contract with Sunshine Health to determine all contracted/covered codes for each membership group.

Billing Codes and Modifiers
Service Type	Units of Measurements	Procedure code	Modifier	Procedure Code Description	Units
Primary Care Services	Visit	99212	*	OFFICE/OUTPATIENT ESTABLISHED SF MDM 10-19 MIN	Unit
Primary Care Services	Visit	99213	*	OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20-29 MIN	Unit
Primary Care Services	Visit	99214	*	OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30-39 MIN	Unit

*Please refer to the Medicaid Fee Schedule and the Billing and Procedure Coding Guide for a list of approved modifier codes.

Important Links

Timely Claim Submission

Providers must submit claims in a timely manner as indicated in the following table.

Initial Claim*		Reconsiderations or Claim Dispute**		Coordination of Benefits***
Participating	Non-Participating	Participating	Non-Participating	Participating	Non-Participating
180 days	365 days	90 days	180 days	90 days	90 days

*In an initial claim, days are calculated from the date of service to the date received by Sunshine Health.

** In a reconsideration or claim dispute, days are calculated from the date of the explanation of payment/correspondence issued by Sunshine Health to the date the reconsideration is received by Sunshine Health.

*** For coordination of benefits, days are calculated from the date of explanation of payment from the primary payer to the date received by Sunshine Health.

Process for Claims Reconsiderations and Disputes

All requests for corrected claims or reconsiderations/claim disputes must be received within 90 days from the date of the original explanation of payment or denial.

Prior processing will be upheld for corrected claims or claim disputes received following the 90-day period unless there is a qualifying circumstance and appropriate documentation to support the qualifying circumstance.

Qualifying circumstances may include:

A catastrophic event that substantially interferes with normal business operation of the provider or damage or destruction of the provider’s business office or records by a natural disaster
Provider documentation showing member refused or was unable to provide member identification card and provider was unaware the member was eligible for services at the time services were rendered

Claim Payment Disputes

(Related to untimely filing, incidental procedure, unlisted procedure code)

Before Oct. 1, 2021
WellCare Health Plans Claim Payment Disputes
P.O. Box 31370
Tampa, FL 33631-3370

On or After Oct. 1, 2021
Sunshine Health
Attn: Adjustments/Reconsiderations/Disputes
P.O. Box 3070
Farmington, MO 63640-3823

Provider on Behalf of Self – Medical Appeals

Providers can request an appeal for the following types of denials:
- No authorization claims denials.
- Authorization denials due to member not meeting medical necessity authorization denials and medical necessity, in addition to, benefits exhausted and non-covered procedures.

Before Oct. 1, 2021
WellCare Health Plans Claim Payment Disputes
P.O. Box 31370
Tampa, FL 33631-3370

On or after Oct. 1, 2021
Sunshine Health
Attn: Adjustments/Reconsiderations/Disputes
P.O. Box 3070
Farmington, MO 63640-3823

Utilization Management

Utilization Management Phone number: 1-844-477-8313 and follow prompts for services required.

Standard hours of operation: Monday to Friday from 8 a.m. to 8 p.m. Eastern.
Weekend and After-Hours on Call-Numbers: (all products): 1-844-477-8313.

Provider Changes

Adding Providers to Existing Group or Practice

A contracted medical or behavioral health practice that would like to add a practitioner should email all relevant documentation to practitioneradds@centene.com and include the following:
- List of Affiliated Providers (LOAP)/Practitioner Roster (for additions only)
- Disclosure of Ownership Form
- Access our LOAP/Practitioner Roster Form (Excel) to utilize as a guide when submitting these types of requests.
The Practitioner Adds Mailbox is equipped with an Auto Response Email to alert the submitter that their request has been received.

Demographic Updates and Changes

A contracted medical or behavioral health practice that would like to update or make any changes to their demographic information should direct their request to SunshineProviderRelations@SunshineHealth.com.
Please include all detailed information to assist in making the appropriate changes.
Providers can also initiate changes like this by visiting our Secure Provider Portal.
- Select “Modify Demographic Information about a specific TIN.”
Providers can also submit their request via the Contact form.

Provider Terminations

Providers should refer to their contracts for specific information about terminating their contracts with Sunshine Health.

In general, providers are required to notify the health plan within 90 days of terminating a provider or providers from a group or contract. Providers who want to terminate an individual practitioner within a practice or group should:

Provide the termination information on office letterhead and include the practitioner’s name, tax identification number, NPI, termination date and membership transfer information, if applicable; AND
Email the request to SunshineProviderRelations@SunshineHealth.com and notify your Provider Relations Representative.

Remittances and PaySpan

Access explanation of payment statements (EOPs), change bank account information register for electronic funds transfers.

If you are currently receiving paper checks and would like to register for EFT, please view a copy of a current paper check. It should contain a Payee ID. This is the Plan Number which will be needed when registering.

The registration for PaySpan is easy and it only takes a few minutes.
Visit PaySpan online, call 1-877-331-7154 or email providersupport@payspanhealth.com.
If your address is incorrect in PaySpan, please update to the correct address. Also, contact Sunshine Health at 1-844-877-8313 to update your address in our systems.

Case Management

Our Case Management team can be reached Monday to Friday from 8 a.m. to 8 p.m. at the phone numbers below. For after hours or weekend assistance, use option 7.

Children’s Medical Services (CMS) Health Plan: 1-866-799-5321, option 2.
Medicaid (MMA), Long Term Care (LTC), Serious Mental Illness Specialty Plan (SMI): 1-866-796-0530, option 2.
Child Welfare Specialty Plan (CWSP): 1-855-463-4100, option 2.

24-Hour Nurse Advice Line

The Nurse Advice Line can assist providers with checking member eligibility. It can also connect members to telemedicine for urgent care visits. Hours of operation are 24 hours a day, 7 days a week.

CMS: 1-866-799-5321 and follow prompts for Nurse Advice Line, Option 1, then Option 7.
MMA and SMI: 1-866-796-0530 and follow prompts for Nurse Advice Line, Option 1, then Option 3, then Option 7.
CWSP: 1-855-463-4100 and follow prompts for Nurse Advice Line, Option 1, then Option 2, then Option 7.

Telemedicine

Members have 24/7 access to receive services virtually through our telehealth vendor, Teladoc. Members can also download the Teladoc app or call 1-800-TELADOC.
Providers may furnish and receive payment for covered, eligible telemedicine services in accordance with this policy and the provider’s scope of practice.

Additional Resources

Access and Availability Timeframe Standards

Sunshine Health establishes and assesses compliance with appointment wait times for various types of visits. Please view our Access and Availability Timeframe Standards.

Find A Provider (FAP) Tool

If you need assistance locating a specialist or facility for a member, please visit our Find a Provider Tool. Here you will be able to search by provider name, NPI and specialty type.

Provider Engagement Account Manager

Use the Find My Account Manager tool.

Community Resources

Sunshine Health Connects links members and caregivers in need with local programs and supports.

For Providers

Stay up to date on provider communication by visiting our For Providers landing page and Provider News page.

Vendors

For contact information, visit the Vendors web page.