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Ancillary Services for MMA, CWSP, SMI and HIV Quick Reference Guide (QRG)

Contact Information, Provider Help and Resources

Sunshine Health covers ancillary healthcare services for our home and community-based members that complements and supports primary medical care. This includes private duty nursing (PDN) and home health (HH) providers. Providers should utilize this educational guide to supplement information outlined in our Provider Manuals.

This Quick Reference Guide (QRG) covers the following products:

  • Sunshine Health Medicaid (MMA)
  • Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP)
  • Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI)
  • Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV)

Utilize these methods to verify 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 can quickly check member eligibility using two datasets:
    • The member’s date of service, member name and date of birth
    • The member’s Medicaid identification number and date of birth
      • Note: The correct plan type must be selected

Coordination of Benefits

  • Member Coordination of Benefits (COB) information can also be found via the Secure Provider Portal.
  • Providers can also call Provider Services at 1-844-477-8313. Be prepared to share the member’s name and date of birth or the member’s Medicaid identification number and date of birth.

All home health agency providers are required to submit claims though the EVV aggregator HHAeXchange. The following services are in-scope for EVV:

  • Home health services: Attendant care, companion, homemaker, participant direction option (PDO), personal care and respite services.
  • Skilled & intermittent nursing is included with services that fall under private duty nursing (PDN).
  • Sunshine Health is contracted with HHAeXchange to implement the EVV program for all Medicaid products per the 21st Century Cures Act. All home health agency providers are required to submit claims though HHAeXchange.
  • Submit claims to: HHAeXchange.

Billing/Claims: Effective January 30, 2025, Sunshine Health will deny any EVV claims that are not electronically verified or those missing the appropriate exception reason code. To avoid reimbursement delays, we strongly encourage all providers to reduce or eliminate EVV exceptions, including manually edited or adjusted visit times. Additionally, please ensure adherence to timely filing guidelines.

EVV Functionality and Electronic Visit Verification

**Please refer to the 21st Century Cures Act which requires providers delivering personal care services, home health, homemaker, companion, attendant care, respite, Participant Direction Option (PDO) services, and Private Duty Nursing (PDN) services for Medicaid population to electronically validate these services and submit the claims for these services through a compliant Electronic Visit Verification (EVV) system. Electronic Visit Verification (EVV) system effective January 1, 2019 (as required by federal law in the “21st Century Cures Act”).

*** The Florida Agency for Health Care Administration (AHCA) and the Department of Health (DOH) have emphasized reducing exceptions pertaining to the use of EVV.

Helpful resources for providers

Tips: Providers are encouraged to attend our provider Town Halls for Electronic Visit Verification. Providers can sign up, view past EVV Town Hall recordings, and access provider resources and trainings on the Provider Training web page.

**For any inquiries related to EVV or HHAX, please use the secure messaging portal. To send a secure message, log into your member account, select "New," and set the internal dropdown to "No." Choose "Communication" as the message type. Responses will be processed through the HHAX secure message portal. Kindly include Sunshine claim numbers, NPI/TIN, and your contact details for follow-up.

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

Sunshine Health

Use Sunshine Health’s secure portal to check a member’s eligibility, verify benefits, submit a referral to Case Management, submit claims, submit claim reconsiderations, etc.

Availity Essentials

Many of the same functions described above can be completed using the Availity portal. We will inform providers when new functionalities are released.

  • Availity Client Services: If you need assistance, call 1-800-AVAILITY (1-800-282-4548). Assistance Monday through Friday from 8 a.m. to 8 p.m. Eastern.

Prior-authorization requests are processed by Sunshine Health’s Utilization Management (UM) Department. To determine which services require authorization, please refer to our Pre-Auth Check Tool.

  • Standard Hours of Operation: Monday to Friday from 8 a.m. to 8 p.m. Eastern.
  • Weekend and After-Hours on Call-Numbers: 1-844-477-8313.
  • Medical Fax: 1-866-796-0526
  • Pharmacy Services Fax: 1-833-546-1507
  • Standard requests: Determination within five calendar days of receipt of request.
  • Urgent requests: Please call 1-844-477-8313. Urgent requests are made when the member’s 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.

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, use option 7.

Sunshine Health (Medicaid)

Member Referrals to Case Management 

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

Sunshine Health Payer ID: 68069

Important Links

Note: Medicaid providers must follow the AHCA enrollment and billing requirements. For more information, consult this guide.

Covered Services

  • Home visit services provided by a registered nurse (RN) or a licensed practical nurse (LPN).
  • Home visits provided by a qualified home health aide (HHA).
  • Private duty nursing (PDN) for children under 21 years of age.
  • Personal care services for children under 21 years of age.

For more information regarding covered services refer to the AHCA Home Health Services resource.

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

Billing Codes and Modifiers

Service Type

Units of Measurements

Procedure Code

Modifier

Procedure Code Description

Units

Private Duty Nursing (PDN)

Hour

S9123

**

PDN rendered by a Registered Nurse (RN) (2-4 hours per day)*

Hourly

PDN

Hour

S9124

**

PDN rendered by a Licensed Practical Nurse (LPN) (2-24 hours per day)*

Hourly

Home Health (HH) Visit

Visit

T1030

**

LPN Visit

Visit

HH Visit

Visit

T1031

**

LPN Visit

Visit

HH Visit

Visit

T1021

**

LPN Visit

Visit

Personal Care MMA

Hour

S9122

**

Personal care rendered by a home health aide (HHA) (1-24 hours per day)

Hourly

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

Important Links

Providers must submit claims in a timely manner as indicated by 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. Providers have the option to file a second-level reconsideration/claims dispute. Second-level requests must be received within 90 days from the date indicated on the decision correspondence from the first-level request.

Quick Tip: Reconsiderations can be submitted via the Secure Provider Portal in response to an underpaid or denied claim.

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 a natural disaster that results in damage or destruction of the provider’s business office or records.
  • Provider documentation showing that a member refused or was unable to provide member identification card and that the provider was unaware the member was eligible for services at the time they were rendered.

Claim Payment Disputes

This includes untimely filing, incidental procedure and unlisted procedure code.

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.

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

For more information about the process, visit the Medicaid Member and Provider Appeals Processes Guide.

Overpayment Refund Address

When a facility, group or practice identifies an overpayment, a refund should be sent to the address below and 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.

Contact Payspan via the following channels:

Note: If your address is incorrect in PaySpan, please update it using the Provider Demographic Updates Tool or by calling Provider Services at 1-844-877-8313.

We encourage providers to keep their demographic information up-to-date using our online tool.

Providers can use our online tools to add a new practitioner or facility, start the credentialing process or update your Affiliated Providers (LOAP)/Practitioner Roster.

Enrollment Tools

Credentialing Tools

Note: 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 60 days to complete. We will not backdate effective dates due to services provided ahead of the practitioner’s enrollment.

Provider Terminations

Providers can use the Provider Demographic Updates Form to submit these requests.

Contact Information, Provider Help and Resources

Medicaid (MMA)

  • Provider Services: All Products      
    • Call: 1-844-477-8313 (All products)        
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern
  • Pharmacy Services: All Products
    • Call: 1-800-460-8988, option 2    
    • Hours: 24 hours a day, 7 days a week
  • Member Services: MMA & SMI
    • Call: 1-866-796-0530        
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern
  • Member Services: CWSP
    • Call:1-855-463-4100       
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern
  • Member Services: HIV      
    • Call: 1-866-796-0530
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern
  • Member Services: CMS
    • Call: 1-866-799-5321
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern

Learn about our Provider Engagement Account Managers (PEAMs) and how they can help you and your practice. Our teams are regionally based and directly engage with parents and providers in the community. Our PEAMs can meet with you in-person or virtually to assist with a variety of services designed to support you and your child’s success. The following channels will help you contact Sunshine Health and stay informed about the latest policies, procedures and news:

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.

  • MMA/LTC/HIV: 1-866-796-0530 and follow prompts for Nurse Advice Line, then option 1, option 3 and option 7.
  • CWSP: 1-855-463-4100 and follow prompts for Nurse Advice Line, then option 1, option 2 and option 7.
  • CMS: 1-866-799-5321 and follow prompts for Nurse Advice Line, then option 1 and option 7.

If you are struggling with alcohol or drug use, experiencing ongoing anxiety or depression or undergoing a crisis, contact the 988 Lifeline using the options most convenient to you. Services are confidential, free of charge and available 24/7, 365 days a year.

Training

Sunshine Health offers a wealth of training opportunities. Providers and their staff can register for our live Provider Town Halls, which are held virtually and in-person; view videos of past webinars; or take self-paced online classes.

Telehealth

Members have 24/7 access to receive services virtually through our telehealth vendors below. Providers may furnish and receive payment for covered, eligible telehealth services in accordance with this policy and the provider’s scope of practice.

Access and Availability Timeframe Standards

Sunshine Health establishes and assesses provider compliance with appointment wait times for various types of visits. View the Access and Availability Timeframe Standards to find the guidelines that apply to your organization.

Find A Provider (FAP) Tool

This tool can help members find a specialist or facility. Search by provider name, National Provider Identifier (NPI) and specialty type.

Community Resources

Links members and caregivers in need with local programs and support.

Vendors 

Visit our vendor resource page to find subcontractors and vendors and how to contact them.