Vendors
Sunshine Health has contracted with the following vendors for service:
- Access Behavioral Health (Medicaid, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-866-477-6725
- abhinfo@bhcpns.org
- Delegated function: Coverage of Services (Behavioral Health), Provider Services
- Delegated function description: Utilization Management (authorizations), Network Management, Provider Credentialing & Contracting, Claims & Provider Payment
- Services: Behavioral Health Services, in-lieu services, inpatient and outpatient services, Region 1 only
- Exclusions: Regions 2-11 will be managed by the Health Plan
- Alivi (Long Term Care, Comprehensive LTC)
- Reservations: 1-888-863-0248 (TTY 711) between 8 a.m. and 5 p.m. Eastern, Monday through Friday
- Ride Assist (Where’s My Ride?): 1-888-863-0248 (24/7, 365 days a year)
- Delegated function: Coverage of Services (Transportation), Enrollee Services, Quality, Provider Services
- Delegated function description: Enrollee Material, Enrollee Toll-Free Help Line, Satisfaction & Experience Surveys (Enrollee and/or Provider), Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
- Services: Non-Emergent Transportation
- Exclusions: Non-Long Term Care and Comprehensive Lines of Business; Emergency Transportation
- Alivi (Medicare)
- Reservations: 1-855-519-6684 between 8 a.m. and 5 p.m. Eastern, Monday through Friday
- Ride Assist (Where’s My Ride?): 1-855-519-6684 (24/7, 365 days a year)
- Delegated function: Coverage of Services (Transportation), Enrollee Services, Quality, Provider Services
- Delegated function description: Enrollee Material, Enrollee Toll-Free Help Line, Satisfaction & Experience Surveys (Enrollee &/or Provider), Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
- Services: Non-Emergent Transportation
- Exclusions: Emergency Transportation, Ambulance
- BioTelemetry (Medicaid, Medicare, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-888-312-2328
- Delegated function: Coverage of Services (Disease Management)
- Delegated function description: Care Coordination/Case Management, Disease Management
- Services: Biometric Screening and monitoring, On-Demand Disease Management Program
- Exclusions: Ages 0-14
- CareCentrix (Medicare)
- 1-800-808-1902
- Delegated function: Coverage of Services (Home Health)
- Delegated function description: Utilization Management (authorizations), Claims Services, Network, Credentialing
- Services: Home Health, Regions 1-7
- Exclusions:
- Durable Medical Equipment (DME), Non-Medicare Lines of Business
- Home Health in Regions 8-11
- CareCentrix (Medicare and Ambetter)
- 1-800-808-1902
- Delegated function: Coverage of Services (Post-Acute Care}
- Delegated function description: Utilization Management (authorizations),
- Services: Post Acute Care
- Exclusions: Medicaid Lines of Business
- Central Florida Orthopedics Associates (Medicaid, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-863-666-3436
- info@cfosa.com
- Delegated function: Provider Services
- Delegated function description: Claims & Provider Payment
- Services: Claims, Provider Payments, Region 7 only
- Exclusions: Commercial (Ambetter), Regions 1-6 and 8-11 are managed by the Health Plan
- Coastal Care Services (Medicaid, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-855-481-0505
- Delegated function: Coverage of Services (DME, Home Health), Provider Services
- Delegated function description: Utilization Management (authorizations), Toll-Free Provider Help Line
- Services: DME & Home Health (MMA, CWSP, SMI, CMS)
- Exclusions:
- Home Infusion Services & PDN: managed by the Health Plan for Medicaid Child Welfare Specialty Plan, & Serious Mental Illness.
- Home Health for Children’s Medical Services Health Plan: Managed by the Health Plan
- Coastal Care Services (Medicare)
- 1-855-481-0505
- Delegated function: Coverage of Services (DME, Home Health), Provider Services
- Delegated function description: Utilization Management (authorizations), Network Management, Provider Credentialing & Contracting, Claims & Provider Payment
- Services: Home Health: Regions 8-11; DME: Statewide
- Exclusions: Home Health Regions 1-7
- Express Scripts (Medicaid, Commercial/Ambetter, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan, Wellcare)
- 1-800-841-3044
- Delegated function: Administration and Management Services, Enrollee Services, Provider Services
- Delegated function description: Pharmacy Benefit Management, Mailing Fulfillment, Network Management, Provider Credentialing & Contracting, Claims & Provider Payment, Toll-Free Provider Help Line
- Services: Pharmacy Benefit Management
- Dental MCOs - Services not managed by Sunshine Health
- Dermatology Network Solutions [parent company Provider Network Solutions] (Medicare)
- 1-844-222-3535
- Delegated function: Coverage of Services (Dermatology), Provider Services
- Delegated function description: Utilization Management (authorizations), Network Management, Provider Contracting, Claims & Provider Payment
- Services: Dermatology
- Exclusions: All counties except Miami-Dade, Broward, Palm Beach, Martin, St. Lucie will be Managed by the Health Plan
- DentaQuest (Medicare)
- 1-833-206-6288
- Delegated function: Coverages of Services, Enrollee Services, Provider Services, Quality
- Delegated function description: Utilization Management, Network Management, Provider Credentialing and Recredentialing, Claims Processing, Member Call Center, Provider Call Center, Quality Improvement
- Services: Dental Services
- Exclusions: Non-Medicare Lines of Business
- Envolve Dental (Commercial/Ambetter)
- 1-855-735-4395
- Delegated function: Coverage of Services (Dental), Provider Services
- Delegated function description: Utilization Management (authorizations), Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Claims & Provider Payment
- Services: Dental Services
- Exclusions: Medicaid, Children's Medical Services Health Plan Title XIX and Title XXI
- Envolve Vision (Medicaid, Commercial/Ambetter, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-800-531-2818
- Delegated function: Coverage of Services (Vision), Provider Services
- Delegated function description: Utilization Management (authorizations), Service Authorization, Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
- Services: Vision Services (Optometry, Ophthalmology)
- Evolent
- Cardiology
- Medicare
- 1-888-999-7713
- Delegated function: Coverage of Services
- Delegated function description: Utilization Management
- Exclusions: Emergent services, Non-Elective Inpatient Services
- High-Tech Radiology and Cardiac Imaging
- Medicaid, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan
- Child Welfare Specialty Plan
- Commercial (Ambetter)
- Medicare
- Delegated function: Coverage of Services
- Delegated function description: Utilization Management, Service Authorization, Coverage of Services, Toll-Free Provider Help Line, Provider Complaint System,
- Exclusions: Long Term Care Line of Business
- Oncology
- Medicaid (MMA), Medicare, Commercial (Ambetter), Child Welfare Specialty Plan (CWSP), Serious Mental Illness (SMI) and Children's Medical Services Health Plan (CMS)
- 1-888-999-7713
- Delegated function: Coverage of Services
- Delegated function description: Utilization Management
- Exclusions: Long Term Care Line of Business
- PT, OT, ST Therapy
- Commercial (Ambetter)
- 1-800-424-4909
- Delegated function: Coverage of Services
- Delegated function description: Utilization Management, Service Authorization, Coverage of Services, Toll-Free Provider Help Line, Provider Complaint System
- Exclusions: Non-Ambetter Line of Business
- Cardiology
- Florida Care Management Services Agency (FCMSA) (Long Term Care)
- 1-877-462-1200
- Delegated function: Coverage of Services, Enrollee Services
- Delegated function description: Care Coordination/Case Management, Utilization Management, Service Authorization, Enrollee Toll-Free Help Line
- Services: Care Coordination/Case Management, Utilization Management
- Services: Care Coordination/Case Management, Utilization Management for a subset of members in Regions 9-11
- Exclusions: Regions 1 to 8
- GT-Independence (Long Term Care)
- 1-877-659-4500
- Delegated function: Coverage of Services, Enrollee Services
- Delegated function description: Participant Direction Option (PDO), Enrollee Material, Enrollee Toll-Free Help Line, Mailing Fulfillment
- Services: PDO
- Health Network One [contracts providers under Therapy Network of Florida] (Medicaid, Child Welfare Specialty Plan, Serious Mental Illness)
- 1-800-595-9631
- Delegated function: Coverage of Services (Therapy), Provider Services
- Delegated function description: Utilization Management (authorizations), Service Authorization, Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
- Services: Only Free Standing Facilities for PT, OT, ST for members 3 years & older
- Exclusions: Ages 0-2 will be managed by the Health Plan; Outpatient Hospital, PPEC, EIS, Tertiary, Respiratory Therapy
- Health Network One (Medicare)
- 1-800-595-9631
- Delegated function: Coverage of Services (Dermatology), Provider Services
- Delegated function description: Utilization Management (authorizations), Service Authorization, Network Management, Provider Credentialing & Contracting, Claims & Provider Payment
- Services: Dermatology
- Exclusions: All counties except Lake, Orange, Osceola, Seminole will be managed by the Health Plan
- Hearing Care Solutions (Medicare)
- 1-866-344-7756
- Delegated function: Coverage of Services (Hearing), Provider Services
- Delegated function description: Enrollee Toll-Free Help Line, Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
- Services: Audiology
- Exclusions: Non-Medicare Lines of Business
- HearUSA (Medicaid, Commercial/Ambetter, Comprehensive LTC, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-855-242-4935
- Delegated function: Enrollee Services, Provider Services
- Delegated function description: Enrollee Toll-Free Help Line, Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
- Services: Audiology
- Exclusions: Medicare
- HHAeXchange (Medicaid, Children's Medical Services Health Plan)
- 1-844-477-8313
- Delegated function: Coverage of Services, Administration & Management Services
- Delegated function description: Participant Direction Option (PDO), EVV Vendor, Electronic Visit Verification
- Services: EVV, Billing Services, Portal
- LabCorp (Medicaid, Commercial/Ambetter, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-800-845-6167
- Delegated function: Provider Services
- Delegated function description: Lab vendor
- Services: Lab Services, Specialized Testing, STAT & Same Day Testing
- LabCorp (Medicare)
- 1-800-845-6167
- Delegated function: Provider Services
- Delegated function description: Exclusive only for Wellcare Medicare
- Services: Lab Services, Specialized Testing, STAT & Same Day Testing
- Little Havana Activities & Nutrition Center (Long Term Care)
- 1-305-858-0887
- Delegated function: Provider Services, Enrollee Services
- Delegated function description: Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment, Mail Fulfillment
- Services: LTC Provider Services, Only Regions 9-11
- Exclusions: Regions 1-8
- Liberty Dental Plan (Children Medical Services Health Plan Title XXI)
- 1-888-352-7924
- Delegated function: Coverage of Services (Dental), Coverage of Services, Provider Services
- Delegated function description: Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment, Enrollee Material, Enrollee Toll-Free Help Line, Utilization Management, Service Authorization
- Exclusions: Medicaid, Ambetter, Medicare & Children's Medical Services Health Plan Title XIX
- Medical Transportation Management (MTM) (Children's Medical Services Health Plan)
- Routine Reservations: 1-844-399-9469 (TTY 711) between 8 a.m. and 7 p.m. Eastern, Monday through Friday, and 8 a.m. to 5 p.m. Eastern Saturday
- Ride Assist (Where’s my Ride): 1-888-597-1185 (24/7, 365 days a year)
- Reservations
- Delegated function: Coverage of Services (Transportation), Enrollee Services, Quality, Provider Services
- Delegated function description: Enrollee Material, Enrollee Toll-Free Help Line, Satisfaction & Experience Surveys (Enrollee &/or Provider), Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
- Services: Non-Emergent Transportation
- Exclusions: Non-Children’s Medical Services Health Plan; Emergency Transportation
- Medical Transportation Management (MTM) (Medicaid, Comprehensive LTC, Serious Mental Illness, Child Welfare Specialty Plan, Children's Medical Services Health Plan)
- Delegated function: Coverage of Services (Transportation), Enrollee Services, Quality, Provider Services
- Delegated function description: Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
- Services: HCBS Therapy (art, equine, music, pet)
- Ages 21 & older for Medicaid, Comprehensive LTC, Serious Mental Illness; Or
- EPSDT under age 21
- Exclusions:
- Under age 21 for Non-Medicaid, Comprehensive LTC, Serious Mental Illness; Or
- Non-EPSDT under age 21
- Authorizations are issued by the Health Plan
- ModivCare (Medicaid, Child Welfare Specialty Plan, Serious Mental Illness)
- Reservations between 8 a.m. and 5 p.m. Eastern, Monday through Friday:
- Medicaid and Child Welfare Specialty Plan: 1-877-659-8420
- Serious Mental Illness: 1-877-659-8412
- Ride Assist (Where’s my Ride) (24/7, 365 days a year):
- Medicaid and Child Welfare Specialty Plan: 1-877-659-8421
- Serious Mental Illness: 1-877-659-8413
- Reservations
- Delegated function: Coverage of Services (Transportation), Enrollee Services, Quality, Provider Services
- Delegated function description: Enrollee Material, Enrollee Toll-Free Help Line, Satisfaction & Experience Surveys (Enrollee and/or Provider), Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
- Services: Non-Emergent Transportation
- Exclusions: Non-Medicaid, Child Welfare Specialty Plan, and Serious Mental Illness Lines of Business; Emergency Transportation
- Reservations between 8 a.m. and 5 p.m. Eastern, Monday through Friday:
- Premier Eye Care (Medicare)
- 1-855-749-1911
- Delegated function: Coverage of Services, Provider Services
- Delegated function description: Utilization Management, Network Management, Provider Credentialing, Toll-Free Member Calls, Toll-Free Provider Calls, Provider Complaints
- Services: Vision Services
- Exclusions: Medicaid, Commercial/Ambetter, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children Medical Services
- Quest Diagnostics (Medicaid, Commercial/Ambetter, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-866-697-8378
- Delegated function: Provider Services
- Delegated function description: Lab vendor
- Services: Lab Services, Specialized Testing, STAT & Same Day Testing
- Quest Diagnostics (Medicare)
- 1-866-697-8378
- Delegated function: Provider Services
- Delegated function description: Lab vendor.
- Services: Lab Services, Specialized Testing, STAT & Same Day Testing
- TurningPoint (Medicaid, Medicare, Commercial/Ambetter, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children Medical Services)
- 1-855-415-7483
- Delegated function: Coverage of Services
- Delegated function description: Utilization Management, Service Authorization, Toll-Free Provider Help Line, Provider Complaint System
- Services: Cardiac Procedures and ENT
- Exclusions: Long Term Care Line of Business