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Caregiver Support Services For Non-Medicaid Caregivers

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

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 not required and there is no limit to services, however services must be deemed medically necessary by CMS Health Plan. As such, the plan is authorized to access and review relevant records. The caregiver receiving the service must not have any other insurance coverage.

Referrals

Referral by a CMS Health Plan Care Manager is required.

Utilization Management

Reach Utilization Management at 1-844-477-8313 and follow prompts for services required. Standard hours of operation are Monday to Friday from 8 a.m. to 8 p.m. Eastern.

Claims

Service must be provided by one of the following types of qualified practitioners:

  • Physician
  • Psychiatrist
  • PPA
  • Psychiatric ARNP
  • LPHA (Licensed Practitioner of the Healing Arts)
  • Master’s level CAP
  • Master’s level practitioner

Description of the Benefit: Individual counseling and therapy services for caregivers to address caregiver burnout, emotional distress and depression.

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 CMS Health Plan to determine all contracted/covered codes for the membership.

Caregiver Therapy Benefit Code

CPT/HCPC/Rev Code

Procedure Code Description

Modifier

H2019

 

HR - HS

Important Links

Timely Claim Submission

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

Timely Claim Submission

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)

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.

After Oct. 1, 2021

Sunshine Health
Attn: Adjustments/Reconsiderations/Disputes
P.O. Box 3070
Farmington, MO 63640-3823

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:

  1. 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
  2. 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.

Case Management

Our Case Management team can be reached Monday to Friday from 8 a.m. to 8 p.m. at 1-866-799- 5321, 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. Call 1-866-799-5321 and follow prompts for Nurse Advice Line.

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.