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Behavior Analysis (BA) — Provider Quick Reference Guide

FAQ: Frequently Asked Questions

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
    • Comprehensive MMA, SMI, HIV/AIDS
    • Child Welfare Specialty Plan  (CWSP)
    • Children Medical Services (CMS) Title 19 and Title 21 
    • Ambetter

Verifying Member Eligibility

These suggestions are not a guarantee of coverage.

  • Verify member eligibility by using the Sunshine Health Secure Provider Portal to confirm eligibility quickly and efficiently.
  • Using the portal, any registered provider is able to quickly check member eligibility by entering the member’s name and date of birth, or Medicaid ID number and date of birth, along with the date of service.
  • It is essential to select the correct “Plan Type” when performing an eligibility search to ensure accurate results.
  • Member Coordination of Benefits (COB) information can also be found in the Secure Provider Portal.
  • Alternatively, you can call Provider Services at 1-844-477-8313. Please provide the member's name and date of birth or their Medicaid ID number and date of birth.

Member ID Cards

Sunshine Health (Comprehensive MMA, CWSP, SMI, HIV/AIDS)

Medicaid Member ID card

Children Medical Services (CMS) Title XXI (21)

CMS Health Plan Title 21 Member ID Card

Children Medical Services (CMS) Title XIX (19)

Ambetter Premier (formerly known as Core)

Ambetter Health Premier Member ID Card (Core)

Ambetter Value

Ambetter Health Value Member ID Card

Definitions:

  • MMA (Managed Medical Assistance): This Medicaid program provides comprehensive medical and behavioral health services, including ABA services, to Medicaid recipients who opted out of a specialized plan.
  • SMI (Sunshine Health Mindful Pathways Specialty Plan): This Medicaid program offers medical and behavioral health services, including ABA services, to members aged 6 and older who have one or more of the following conditions: psychotic disorders, delusional disorder, bipolar disorder, schizoaffective disorder, obsessive-compulsive disorder and major depression.
  • CWSP (Sunshine Health Pathway to Shine Specialty Plan): This Medicaid program provides medical and behavioral health services, including ABA services, to children in the child welfare system, including those in foster care, receiving adoption services, or at risk of being removed from their homes.
  • HIV/AIDS (Sunshine Health Power to Thrive Specialty Plan): This Medicaid program offers specialized healthcare services to individuals living with HIV/AIDS.
  • Children Medical Services (CMS): This program is designed for individuals who are eligible for Medicaid or KidCare and have special healthcare needs.
    • CMS Title XIX (19): This Medicaid program provides medical and behavioral health services, including ABA services, to members ages 0-20 years with special healthcare needs who qualify for Medicaid coverage. There is no copayment or premium cost to the member.
    • CMS Title XXI (21): Children’s Health Insurance Program (CHIP): This program provides medical and behavioral health services, including ABA services, to children ages 0-18 years with special healthcare needs who qualify for KidCare. These individuals are not Medicaid recipients. There may be a copayment or premium cost for the member, which is determined by family income.
  • Ambetter Health/Marketplace
    • Premier Plan: This product has our broadest network of healthcare providers and hospitals.
    • Value Plan: This product has select healthcare providers and hospitals in the network. This plan requires a referral to providers outside the members’ assigned Primary Care Provider.

Breakdown of Applicable Products in FLMMIS

Please review below examples of how each plan product will appear in Florida Medicaid Management Information System (FMMIS).

Product Name

FLMMIS Provider Name

FLMMIS Plan Name

Managed Medical Assistance (MMA)

Sunshine Health

SMMC MMA Capitated

Sunshine Health Pathway to Shine (CW)

Sunshine Health

SMMC MMA Child Welfare Capitated

Sunshine Health Mindful Pathways (SMI)

Sunshine Health

SMMC MMA Specialty Capitated

Children’s Medical Services (CMS) Title 19

Children’s Medical Services Health Plan

SMMC MMA Specialty Capitated

Children’s Medical Services (CMS) Title 21

N/A

N/A

Managed Medical Assistance (MMA)

FMMIS MMA Sample

Sunshine Health Mindful Pathways (SMI)

FMMIS SMI Sample

Sunshine Health Pathway to Shine (CW)

FMMIS CW Sample

Children’s Medical Services (CMS) Title 19

FMMIS CMS Title 19 Sample

Continuity of Care (COC)

Sunshine Health coordinates BA services for all members who are new to our plan to ensure there is no interruption in care. This process ensures continuous care for members with previous authorizations or who are undergoing an active course of treatment. This includes care previously authorized to a non-participating provider. Effective February 1, 2025, the continuity of care (COC) period for new BA Comprehensive MMA, SMI, CWSP, HIV/AIDS and CMS Title 19 members is 120 days from the date of eligibility for this transitional period.

Providers do NOT need to do anything if an existing authorization is in place. Those authorizations will be extended through the COC period. Reauths will not be required until 30 days prior to the end of the COC authorization.

After the effective date of the new enrollment:

  • Providers should continue providing all medically necessary services that were previously authorized, regardless of whether the provider is participating in the plan’s network. Sunshine Health will pay for previously authorized services for up to 120 days for Comprehensive MMA, SMI, CWSP, HIV/AIDS and CMS Title 19 members.
  • For Comprehensive MMA, SMI, CWSP, HIV/AIDS and CMS Title 19 members, Sunshine Health will pay for previously authorized services for up to 120 days after the effective date of enrollment and pay providers at the rate previously received.
  • For enrollees that change plans during the initial COC period, the Managed Care Plan will coordinate with the previous plan to ensure existing prior authorizations will be honored.
  • During the transition of care, we will backdate a request up to 30 calendar days.
  • Out-of-network providers will be authorized during the COC period or until the authorization expires, whichever occurs first. Members must select an in-network provider and BA services will require prior auth after the COC period ends.
  • Sunshine Health will honor existing prior authorizations through May 31, 2025. If the pre-approved authorization extends beyond May 31, 2025, Sunshine will extend the authorization through July 31. 2025. This includes services provided by non-par providers. After the COC period ends, members must select an in-network provider and BA services will require prior authorization.

Note: The 120-day COC period applies to all Sunshine Health Medicaid and CMS Title 19 members that were receiving ABA services prior to the February 1, 2025, transitional period. After the 120 day COC period ends, refer to Sunshine Health’s MMA Provider Manual for our standard COC time frames.

BA Authorizations

Prior authorization is required for all BA services. When necessary, 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 5 calendar days of receipt of request.
  • Urgent requests: Please call 1-844-477-8313. Urgent requests are made when the member or their 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.
  • BA prior authorization requests can be submitted for up to 6 months of services.

Submit authorization requests via one of the following:

  • Online: via the Sunshine Health Secure Provider Portal
  • Utilization Management Phone number: 1-844-477-8313
  • BA Fax: 1-844-208-9113
  • Pharmacy Services Fax: 1-833-546-1507
  • Standard hours of operation: Monday- Friday from 8 a.m. to 8 p.m. Eastern
  • Weekend and After-Hours on Call-Numbers (For All Products): 1-844-477-8313

Required Documentation

All documentation must reflect the individual assessments, needs and interventions of the recipient.

Initial Behavior Assessment and Behavior plan requests:

  • A referral for BA services is required as follows:
    • The recipient must be referred by an independent physician or practitioner qualified to assess and diagnose disorders related to functional impairment, including:
      • Primary care physician with family practice, internal medicine or pediatrics specialty;
      • Board certified or board eligible physician with specialty in developmental behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, adult or child psychiatry
      • Child psychologist

Comprehensive Diagnostic Evaluation (CDE)

A comprehensive diagnostic evaluation (CDE) performed according to national evidence-based practice standards. CDEs may be performed by a multidisciplinary team or individual practitioner. In any case, the CDE must be led by a licensed practitioner working within their medical, developmental, or psychological scope(s) of practice. The CDE must include assessment findings and treatment recommendations appropriate to the recipient. For example, the CDE may include data from behavioral reports by parents, guardians, and/or teachers; diagnostic testing related to recipients‘ development, behavior, hearing, and/or vision; genetic testing; and/or other neurological and/or medical testing.

Behavior Assessment and Behavior Treatment plan

  • Providers should request re-assessment units with their treatment request.
  • Florida Medicaid Behavior Analysis service policy identifies a 40-hour per week limit for behavior analysis services.
  • Behavior assessment and behavior plan with specific criteria are listed in the Florida Medicaid Behavioral Analysis Coverage Policy (PDF).
  • The behavior assessment and behavior plan must be signed by the Lead Analyst and the recipient’s parent or guardian.
  • The Vineland-3 and BASC-3 PRQ core assessments are required to be included for initial assessment and annually for reassessments.
  • The complete scoring reports for the Vineland and BASC, including outcome measure scores, must be submitted with service at each prior authorization request.

Assessment and Behavior Plan for Reauthorization and Continuation of Services

  • In addition to the documentation requirements indicated in Florida Medicaid Behavioral Analysis Coverage Policy (PDF), assessments and behavior plans for reauthorization and continuation of services must include:
  • Data reflecting progress of all behaviors targeted for improvement. Each behavior under treatment must have its own data table and corresponding graph. A narrative discussion of progress and a statement of justification for continuation of care at the intensity level requested. If significant clinical progress is not made over the course of an authorization period, the provider must explain why clinically significant progress was not made and treatment changes to promote progress.

Note: Please use the Treatment/Service Request Forms for fax submission.

BA services must be rendered by one of the following:

  1. Lead Analysts who are one of the following:
    • Board certified behavior analyst (BCBA) credentialed by the Behavior Analyst Certification Board.
    • Florida certified behavior analyst (FL-CBA) credentialed by the Behavior Analyst Certification Board.
    • Practitioner fully licensed in accordance with Chapters 490 or 491, F.S., performing within their scope of practice.
  2. Board certified assistant behavior analysts (BCaBA) credentialed by the Behavior Analyst Certification Board working under the supervision of a BCBA.
  3. Registered behavior technicians (RBT) credentialed by the Behavior Analyst Certification Board working under the supervision of a BCBA or BCaBA.

Claims

Behavioral Analysis (BA) Covered Services

Behavior analysis (BA) services are covered for CMS Title 21 and Title 19 members. They are highly structured interventions, strategies, and approaches provided to decrease maladaptive behaviors and increase or reinforce appropriate behaviors for members. For more information about covered services, refer to AHCA’s Behavior Analysis Services Provider Information resource.

Description of the Specialty: Behavior analysis (BA) services are highly structured interventions, strategies, and approaches provided to decrease maladaptive behaviors and increase or reinforce appropriate behaviors.

Methods for Claims Submission

For both paper and electronic data interchange (EDI) claim submissions starting February 1, 2025, the appropriate Center for Medicare and Medicaid Services (CMS) billing forms are required:

  • CMS 1450 (UB04) for facilities.
  • CMS 1500 for professionals.

There are several ways to submit claims to us:

Secure Provider Portal

  • Participating (PAR) and Non-Participating (Non-PAR) providers interested in billing directly to Sunshine Health's provider portal can do so via the Secure Provider Portal.  
  • PAR and Non-PAR providers can gain access to Sunshine Health's portal by following these steps:
    • Providers must add their Taxpayer Identification Number (TIN) to Sunshine's back-end system.
      • PAR: Provider must complete the JON (Join Our Network) process (Contracting, Credentialing, etc.).
      • Non-PAR: Provider must file a clean claim to Sunshine Health.
    • Once a TIN is loaded in our system, please wait at least two business days to be added to our system (this applies to PAR and Non-PAR providers.)
    • To determine if a claim has made it through our front-line claims edits, please contact:

Claims Submissions

Health Plan

Claim Type

Payer ID #

Paper Claim Mailing Address

Sunshine Health, CMS, SMI, CWSP, HIV/AIDS

Professional and Institutional

Sunshine Health: 68069

 

Attn: Claims Department
P.O. Box 3070
Farmington, MO 63640- 3823

Ambetter Health

Professional and Institutional

68069

Attn: Claims Department
P.O. Box 5010
Farmington, MO 63640-5010

Note: Please reference the vendor provider manuals for their individual payer IDs.

Billing

In general, Sunshine Health follows Centers for Medicare & Medicaid Services (CMS) billing requirements. Please refer to your contract to determine contracted products, negotiated rates and Fee Schedules. For additional questions, contact Sunshine Health Provider Services at 1-844-477-8313.

  • Clean claims will be adjudicated (finalized as paid or denied) at the following levels:
    • 85% of all clean claims submitted within 7 days.
    • 95% of all clean claims submitted within 10 days.
    • 98% of all clean claims submitted within 20 days.
  • Adjusted claims, requests for reconsideration and disputed claims will be finalized to a paid or denied status 30 calendar days of receipt.

For additional questions, contact Sunshine Health Provider Services at 1-844-477-8313 or Ambetter Health Provider Services at 1-877-687-1169.

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.

Overpayment Refund Address  

When a facility, group or practice identifies an overpayment, a refund should be submitted to the address indicated below to include all applicable claims for which the refund is being submitted.  

Sunshine Health 
Attn: Centene Mgmt. Co - Sunshine State Health Plan 
P.O. Box 947986 
Atlanta, GA 30394-7986

Remittances and PaySpan

If you are currently receiving paper checks and would like to switch to Electronic Funds Transfer (EFT), please register with PaySpan.

Register by visiting PaySpan’s website, calling 1-877-331-7154 or emailing providersupport@payspanhealth.com. If your address is incorrect in PaySpan, please update it.

Update Provider Demographics

Providers can use the Provider Demographic Updates form to quickly update their practice information or call 1-844-877-8313.

Credentialing and Provider Changes

To add a new practitioner or facility to your existing Sunshine Health contract please visit the Practitioner Enrollment Request page. This form is restricted for adding a practitioner or facility to an existing, contracted group. If the tax ID is not currently contracted with Sunshine Health, please submit a request to Join Our Network. If a request is submitted for a non-contracted group, the request will be returned to you unprocessed.

To become a participating Registered Behavioral Technician (RBT) with Sunshine Health, you must be board certified by the Behavior Analyst Certification Board when you submit your request to participate in our network. During our enrollment process, if BACB certification cannot be verified, we cannot process the request. You do not need to submit a screenshot or proof. Sunshine Health will verify through the BACB.

For RBTs contracted with Medicaid products, a valid, active and enrolled Medicaid ID must be validated against AHCA’s Provider Master List. This requirement does not apply to Marketplace or Medicare products.

Important: Practitioners should not begin servicing Sunshine Health members until they have received a Provider Enrollment Confirmation letter from Sunshine Health’s Provider Enrollment department. Our enrollment process can take up to sixty (60) days to complete. We will not backdate effective dates due to services provided ahead of the practitioner’s enrollment. For more information, visit:

Contracting

Sunshine Health takes proactive actions that are aimed at creating a comprehensive and high-quality network that meets the needs of its members while ensuring access to necessary services. If you are a non-contracted provider, please submit your request to join our network.

Note: Submitting this inquiry is an important first step in the process, but it does not guarantee entry into our network. This form is not the same as a credentialing application or a signed agreement. The information you provide will be used solely by Sunshine Health to evaluate the potential for offering a new contract, amending an existing one, or adding an additional product to an existing contract. We appreciate your interest and will carefully review your submission.

All contract rate discussions for participating providers are unique and confidential, if you have questions please email sunshinecontracting@sunshinehealth.com and a representative will reach out to speak with you.

Please note, there is a moratorium on new Targeted Case Management and Psychosocial Rehabilitation providers, effective February 1, 2025. 

Case Management

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

Member Referrals to Case Management 

Referrals can be submitted through the Secure Provider Portal under the “Referrals” tab of the Member’s Record. After successful submission, a message will appear confirming this. 

24-Hour Nurse Advice Line and Crisis Line

The Nurse Advice Line can assist providers with checking member eligibility. It can also connect members to telemedicine for urgent care visits. The same number also has a Behavioral Health Crisis Line. 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 select Option 7.
  • MMA and SMI: 1-866-796-0530 and follow prompts for Nurse Advice Line, select Option 1, then Option 3, then Option 7.
  • CWSP: 1-855-463-4100 and follow prompts for Nurse Advice Line, select Option 1, then Option 2, then Option 7.
  • Ambetter Health: 1-877-687-1169 (Relay Florida 1-800-955-8770). Available 24-7, 365 days a year.

988 — Suicide & Crisis Hotline 

If you are struggling with alcohol or drug use, experiencing ongoing anxiety or depression, or experiencing a crisis, dial or text 988, or chat with a trained counselor at 988lifeline.org/chat. This service is confidential, free of charge, and available 24/7, 365 days a year.

Provider Engagement

Sunshine Health has a team of Provider Engagement Account Managers throughout Florida, who are committed to supporting providers and addressing your needs. Learn more about how Provider Engagement can help you.

Our Account Managers are available to assist with a variety of services designed to support the success of your practice. These professionals spend three or more days each week directly engaging with providers in the field.

For inquiries related to operational issues, we kindly ask that you direct these to our dedicated providers service team at 1-844-877-8313 who are equipped to handle those requests promptly and efficiently.

To identify your designated Account Manager, visit our Find Your Account Manager tool.

Additional Resources

  • Access and Availability Timeframe Standards: Sunshine Health establishes and assesses compliance with appointment wait times for various types of visits. Please view Standards for Appointment Scheduling.
  • 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.
  • Community Resources: Our Sunshine Health Community Resource Database connects members and caregivers in need with local programs and supports.
  • For Providers: Stay up to date on provider communication by visiting For Providers and Provider News. On this page, providers can also subscribe to our monthly newsletter.
  • Vendors: Contact information for Sunshine Health’s subcontractors and vendors.

FAQ: Behavior Analysis (BA) Frequently Asked Questions

Updated: February 14, 2025

Claims & Billing

  • Are there different payer IDs for Sunshine Health and CMS?
    • No, the Payer ID is the same: 68069.
    • If you used 68068, it will still come to us. There is no need to resubmit the claim.
  • Where do I submit claims for dates of services (DOS) post-February 1, 2025?
  • What is the claim payment schedule?
    • We run payable cycles four times per week (on Monday, Tuesday, Thursday and Friday). This schedule allows us to process claims quickly, typically within 5-6 business days. This is notably more frequent than AHCA's once-per-week schedule, giving our providers a significant advantage.
  • How long do claims take to process?
    • We process payment cycles four times per week to ensure payments are consistently being issued.
      • Clean claims will be adjudicated (finalized as paid or denied) at the following levels: 
        • 85% of all clean claims submitted within seven days. 
        • 95% of all clean claims submitted within ten days. 
        • 98% of all clean claims submitted within 20 days. 
    • Providers should allow 5-7 business days for clean claims to process.
    • New providers who have never billed us should allow a few additional days.
  • How are Sunshine Health and CMS claims processed?
    • While Sunshine Health and CMS claims are run on the same days, they are processed on separate payable cycles. This indicates they will appear on separate remits and separate 835s.
  • How do providers view Sunshine Health and/or CMS claims in the portal?
    • When looking up claims, providers need to use the dropdown menu to select the specific program. For Sunshine Health member claims, select “Sunshine.” For CMS member claims, select "CMS." Each program's claims can only be viewed when that specific program is selected in the dropdown.
  • What steps should be taken when a provider receives an error code during web portal claim submission?
    • No action is required until the claim shows finalized (paid/denied).
  • How will claims be reimbursed during the COC transition period?
    • Sunshine Health will reimburse the contracted rates for participating providers.
    • For non-participating providers, reimbursement will continue at 100% of the Medicaid Fee Schedule during the 120 day COC period.
    • CMS Title 21 provider rates will remain unchanged, because these members were previously covered by Sunshine Health.
  • I am already seeing claim denials for no authorization.
    • Sunshine Health is monitoring claim processing daily to ensure all denials are appropriate.
    • Please note: CMS Health Plan Title 21 members are not part of this transition, therefore services do require authorization for the claim to pay.
  • How do we proceed with billing the codes with XP Modifiers? With Medicaid they request for us to bill at least $0.01 for the system to accept the claim.
    • To ensure Medicaid claim acceptance for codes 97153XP and 97155XP, continue to bill with a minimum charge of $0.01. This minimal billing prevents claim denials while maintaining compliance with Medicaid. Consistently use the XP modifier for these codes and ensure all documentation supports the service provided.
  • How will  be able to bill under the RBT since the new rosters have not yet been loaded?
    • Provider records are being established based on submitted claims data. To ensure timely processing, please continue submitting claims as usual rather than holding them while roster updates are in progress.
  • Should we bill both RBT on one claim (EQ Health allowed them to be billed for them together in one claim form)?
    • Sunshine Health requires separate claim submissions for RBT services rather than combined claims.
  • What protocol should we follow when submitting claims if the recipient received services in the morning at school with one Registered Behavior Technician (RBT) and then additional services in the afternoon with another RBT? If the claim denies for duplicate in error, should we file a reconsideration or just wait for the system to update and fix itself ?
    • Sunshine Health is reimbursing providers for these services, therefore, please do not hold your claims. You can bill Sunshine Health immediately.
  • How is Sunshine Health handling the reprocessing of denied claims for multiple RBTs providing services on the same day?
    • We are actively reprocessing claims by pulling them and placing them back through the system immediately, rather than waiting for the standard 6-8 week customization period.
  • What is the process to submit claims for the same rendering provider to avoid duplicate denials?
    • To prevent duplicate denials, providers should submit a single claim when billing for the same rendering provider on both the morning and afternoon of the same day.

Direct Deposit

  • Do we have to have a paid paper claim to have access to Payspan? Or can the claim be submitted electronically?
    • Payspan has to be able to validate the Tax ID number with us. If you are already loaded in the system, you should be able to call Payspan to register.
      •  If you are not loaded with us, a claim has to be billed, but it does not have to be a paper claim. It can be submitted electronically. The first claim submission will come back in form of paper EOP and will indicate a registration code.
  • My group is already set up for EFT through Payspan. We continue to add several billing NPIs to our agreement. What is recommended as the best next, step in this scenario?
    • We recommend providers contact Payspan to ensure your organization is set up properly.

Provider Training

Provider Updates

  • Where should provider updates for RBT to BCBA transitions be submitted?
    • This change should be submitted as a "Specialty change" using the Provider Demographics Update (PDU) tool. However, the specialty must be updated with AHCA first and reflected on the Provider Master List (PML). Upon receipt of the request through the PDU tool, please allow up to 30 days to process the request. You will receive a confirmation notice once the change has been processed.
  • During the COC period, how do we add RBTs to our roster? Are we allowed to hire new RBTs in the meantime?
    • Please continue to serve members. We ask that providers share any RBT changes via LOAP (roster) via the Practitioner Enrollment form. Although we do not require credentialing of RBTs, we no longer accept RBT, BCBA, or BCBA enrollment from practitioners who do not have the required certification.
    • These resources can help providers obtain and maintain their certification:
  • Why is my roster showing previously termed practitioners?

Credentialing

  • Is it okay to list the RBT Requirements Coordinator as the supervising analyst because some RBTs may have more than one analyst as a supervisor across members?
    • RBTs assist in delivering behavior-analytic services and practice under the direction and close supervision of an RBT Supervisor and/or an RBT Requirements Coordinator, who are responsible for all work performed by RBTs. Sunshine Health will accept the RBT Requirements Coordinator as a supervising clinician.

Authorizations

  • How far in advance can providers request authorization for services expiring?
    • Sunshine Health asks providers to submit requests within 30 days prior to services expiring.
  • Are authorizations submissions an available function through Availity?        
    • Authorizations can be submitted through both the Availity Login and the Sunshine Health Secure Provider Portal, giving providers multiple options for submitting authorization requests. Either platform can be used to complete and process authorization submissions.
  • I have reassessments expiring this month. What do I do next?
    • Sunshine Health will honor and extend existing authorizations with end dates on or after February 1, 2025, through at least May 31, 2025. No action is required by the provider.
    • If authorizations extend past this date, we will honor extension until July 31, 2025. The extended authorizations will be extended with additional units based on the original approval. No action is required by the provider.
    • If services are needed beyond July 31, 2025, a new authorization must be requested. Visit the Pre-Auth Check tool to check authorizations and find the necessary forms.
  • How do we proceed with submitting the CDE? Do we continue including this?
    • Yes, you must submit the CDE as we follow AHCA’s Behavior Analysis Services Coverage Policy (PDF).
    • The recipient must be referred by an independent physician or practitioner qualified to assess and diagnose disorders related to functional impairment.
    • CDE must be completed by:
      • Primary care physician with family practice, internal medicine, or pediatrics specialty, Board certified or board eligible physician with specialty in developmental behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, adult or child psychiatry and Child psychologist.
  • What is the procedure for submitting a modification request after an authorization has been approved?
    • This process has not changed. Please reach out to our Utilization Management team and request the updates. We prefer fax for these changes.
  • When extending an authorization end date (e.g. to May 31 or July 31) are the service units also extended?
    • Authorizations will be created based on the intensity of services which were previously authorized by EQ Health.
  • How much time will it take for providers to see authorizations in the Provider Portals?
    • We expect authorizations with extensions to be available for viewing in the Secure Provider Portal by February 14, 2025. We ask that providers allow a few more days after this date to view in the Provider Portal. We are working diligently to load the information received from the state, which includes previously authorized services.
  • Will we be able to see EQ Health authorizations from other providers?
    • Yes, providers will be able to see previously authorized services in the Provider Portals. Please allow an additional few weeks before they will be visible in the Provider Portals.
    • Sunshine Health and CMS Health Plan authorizations will have a new internal number assigned.
    • Sunshine Health does a secondary match on authorizations, so if you do not have the updated authorization OR bill with the previous authorization number, we will be able to match that claim for payment.
  • When will I be able to submit authorizations for CMS Title 21 members?
    • COC period is for the members who had been treated previously through EQ Health. Therefore, these changes do not apply to CMS Title 21 as those members were previously being managed by Sunshine Health.
  • What do members who are changing from one insurance to another need to do?
    • Providers do not need to do anything or send anything additional to make us aware.
    • Please note, claims should be directed to Sunshine Health for further processing.
  • If I do not have previously authorized services from EQ Health and I need to request authorization, in what timeframe should I expect to hear back on my request?
    • Authorization requirements for clients starting after February 1, 2025, will be processed within five business days. This turnaround time (TAT) ensures timely review and approval of submitted authorizations, allowing for smooth continuity of client services. Providers can expect a response within five business days from the submission date.

Network and Contracting

  • How will provider credentialing align with the new contract start date?
    • Provider credentialing documentation will be collected concurrent with contract creation. Upon contract execution, all documentation will be processed to ensure provider credentialing is completed prior to the contract effective date.
    • Any members they bill for now will be paid even if they have not been credentialed due to the COC.

Sunshine Health Secure Provider Portal

  • I am a non-participating provider and I need access to the portal. How is this done?
    • You must submit a claim to Sunshine Health and allow it to process. The Taxpayer Identification Number (TIN) in the system is how it will reflect in the Secure Provider Portal.

Availity Essentials Portal & Member ID Cards

  • Does Availity cost money to use?
    • No, Availity is free for providers.
  • I do not see ID cards for some of my members.
    • Currently, the health plan is working through a bulk load process to ensure all active members are reflected within the portal with a copy of their Member ID Card. This is not an indication that the member is not active. Please confirm eligibility to determine active coverage.

Member Information

  • Do members have a choice in health plan coverage?
    • Members have the choice through the open enrollment period to pick a health plan.
    • Under the SMMC program, there are different methods for enrolling, disenrolling and changing from one health plan to another. For more information, visit the AHCA Enrolling in a Health Plan guide.

Telehealth