Transportation Quick Reference Guide (QRG)

Sunshine Health contracts with Alivi to administer all non-emergent medical transportation services for our Medicaid members. Providers should utilize this educational guide to supplement information outlined in our Provider Manual (PDF).

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

• Sunshine Health Medicaid (MMA)
• Comprehensive Long Term Care (LTC)
• 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)

• To schedule a trip for a member, call Alivi reservations at 1-844-352-0140 (TTY: 711) or use the Alivi Provider Portal
• Here’s how members can schedule trips:
  • Call: 1-844-352-0134 Monday through Friday from 8 a.m. to 5 p.m. Eastern
  • Visit: Alivi Member Portal
• Members experiencing problems with a ride in progress can call 1-877-659-8421 (TTY 711) 24 hours a day, seven days a week.
  • Requests must be made 24 hours in advance.
• Members can check the status of trips using the iOS and Android mobile app.

Managed Medical Assistance (MMA) Member Benefits

• Unlimited trips between home, medical appointments and healthcare facilities.
• Routine appointments require 24-hour notice and must be scheduled one business day prior to appointment.
• Services available 24/7, 365 days a year.
• Prior authorization required on trips over 100 miles.

Long Term Care Member Benefits

• Unlimited trips between home, long-term care facilities and long-term care services.
• Routine appointments require 24-hour notice and must be scheduled one business day prior to appointment.
• Services available 24/7, 365 days a year.
• Prior authorization required on trips over 100 miles.
• Three round-trip non-medical trips per month for purposes such as social outings or family visits. Limited to trips within the member’s home county/local area.

Managed Medical Assistance with Long Term Care (Comprehensive LTC) Member Benefits

• Unlimited trips between home, medical appointments, long-term care and healthcare facilities, and long-term care services.
• Routine appointments require 24-hour notice and must be scheduled one business day prior to appointment.
• Services available 24/7, 365 days a year.
• Prior authorization required on trips over 100 miles.
• Three round-trip non-medical trips per month for purposes such as social outings or family visits. Prior authorization required.

Sunshine Health Pathway to Shine Specialty Plan (CWSP) Member Benefits

• Unlimited trips between home, medical appointments and healthcare facilities.
• Routine appointments require 24-hour notice and must be scheduled one business day prior to appointment.
• Services available 24/7, 365 days a year.
• Prior authorization required on trips over 100 miles.
• Three round-trip non-medical trips for purposes such as social outings or family visits. Limited to trips within the member’s home county/local area.

Sunshine Health Mindful Pathways Specialty Plan (SMI) Member Benefits

• Unlimited trips between home, medical appointments and healthcare facilities.
• Routine appointments require 24-hour notice and must be scheduled one business day prior to appointment.
• Services available 24/7, 365 days a year.
• Prior authorization required on trips over 100 miles.
• Three round-trip non-medical trips for purposes such as social outings or family visits. Limited to trips within the member’s home county/local area.

Sunshine Health Power to Thrive Specialty Plan (HIV) Member Benefits

• Unlimited trips between home, medical appointments, long-term care and healthcare facilities, and long-term care services.
• Routine appointments require 24-hour notice and must be scheduled one business day prior to appointment.
• Services available 24/7, 365 days a year.
• Prior authorization required on trips over 100 miles.
• Three round-trip non-medical trips per month for purposes such as social outings or family visits. Prior authorization required.

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.
  

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
  • Note: Utilize these Treatment/Service Request Forms for fax submission online.
• 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.

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

• Provider Reimbursement Schedules and Billing Codes
• Manuals, Forms and Resources
• AHCA Transportation Services Fee Schedule (PDF)
• AHCA Provider General Handbook (PDF)
• Non-Emergency Transportation Services Coverage Policy (PDF)
• Emergency Transportation Services

Note: Medicaid providers must follow the AHCA enrollment and billing requirements. For more information, consult this Sunshine Health guide: Provider Guide: AHCA Rules For Medicaid Enrollment, Billing

Covered Services

Medicaid will pay for non-emergency (land vehicle only) transportation services for a Medicaid eligible recipient who has no other means of transportation to a Medicaid covered service. Examples include, but not limited to:

• Doctor appointments
• Dental appointments
• Mental Health appointments
•  receive dialysis services

Medicaid will pay for medically necessary emergency ground or air ambulance transportation for a Medicaid eligible recipient requiring emergency transportation.

For more information, please refer to the AHCA Non-Emergency Transportation 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. Bill the transportation vendor for covered non-emergency transportation services and the Health Plan for covered emergency transportation services.

Billing Codes and Modifiers

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

Timely Claim Submission

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

*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 are 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 the 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 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

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:

• PaySpan
• Call: 1-877-331-7154
• Email: providersupport@payspanhealth.com
  

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.

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

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:

• Provider Support: Finding the Right Contact
• Provider Services: Call 1-844-477-8313
• Secure Provider Portal: Visit the Secure Provider Portal to check member eligibility, submit claims and more.
• Provider Engagement: Use the Find Your Account Manager tool to find the Provider Engagement Account Manager (PEAM) supporting your specialty and region.
• Claim Concerns: Resolve outstanding claims using the Claim Concerns form.
• Provider News: Bookmark Sunshine Health Provider News to keep up with the latest updates.
• Provider Newsflash: Subscribe to our e-newsletter to get regular updates.
• Provider Resources: Visit Manuals, Forms and Resources to find provider manuals, important forms, scheduling standards and other provider resources.
  

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.