Credentialing

All contracted providers and practitioners have the right to be informed of the status of their credentialing /recredentialing application upon request. Requests should be submitted to the address noted below, or by calling Provider Services at 1-844-477-8313. Written inquiries will be sent back to the practitioner via Restricted Delivery Certified Mail within 14 days of the receipt of the request from the practitioner.

During the credentialing and re-credentialing process, Sunshine Health will obtain information from various sources to evaluate applications. Providers and practitioners have the right to review any primary source information that Sunshine Health collects during this process such as the National Practitioner Data Bank (NPDB), Licensing and Board Certification. However, this does not include the release of references, recommendations or other information that is peer review protected.

The Credentialing Department contacts the applicant by phone and/or letter to inform of any information obtained from an outside primary source that varies from the information provided by the practitioner, and to request a response by the practitioner. Should the provider or practitioner believe any of the information used in the credentialing /recredentialing process to be erroneous, or should any information gathered as part of the primary source verification process differ from what the provider or practitioner submitted on an application, he/she has the right to correct any erroneous information submitted by another party. To request release of such information, a written request must be submitted to the Credentialing Department at the address or email noted below. Upon receipt of this information, the provider or practitioner will have 21 days to provide a written explanation detailing the error or the difference in information to Sunshine Health.  Sunshine Health’s Credentialing Committee will then include this information as part of the credentialing /recredentialing process.

• Requests for credentialing status can be made by calling Provider Services at 1-844-477-8313.
• Requests to release information are to be submitted directly to Sunshine Health, Attn: Credentialing Department at: P.O. Box 459089, Fort Lauderdale, FL 33345-9089.

The Agency for Health Care Administration (AHCA) has created a streamlined application, or Limited Enrollment, for providers who do not hold a Medicaid ID and need to complete basic credentialing which may be a prerequisite to seeking a contract with a Medicaid health plan.

With the implementation of Limited Enrollment in December 2015, providers seeking to participate in a health plan’s network have the option to utilize a web-based Limited Enrollment application wizard which guides them through creation of the application. The streamlined application and corresponding review process allows approved providers to receive their Medicaid IDs faster than with traditional full enrollment.

Upon receipt of a Limited Enrollment application, AHCA will perform several basic credentialing functions, including licensure verification and review of background screening history, including criminal history and federal exclusion database checks.

Successfully obtaining a Limited Enrollment status with Medicaid may eliminate the need for providers to undergo the basic credentialing with each plan with which they seek to contract and may reduce the time it takes for a plan to complete credentialing with a health plan.

NOTE: Assignment of a Medicaid ID does not guarantee a place in the network of any health plan. Each plan may apply their own standards for provider credentialing beyond what is required by Medicaid.

Limited Enrollment is not an option for providers of services to fee-for-service recipients. Fee-for-service providers must seek traditional Full Enrollment in order to directly bill Medicaid for reimbursement.

For those providers of services solely to recipients in a health plan, Limited Enrollment is a valuable option. Additional information on provider enrollment can be found on the AHCA website.

Providers will be able to submit a Limited Enrollment application through the Public Web Portal.

The Limited Enrollment application captures all demographic information, licensure and exclusion databases verification and background screenings in compliance with Affordable Care Act provider screening requirements.

Limited Enrollment is available now.

Limited providers will be required to complete a renewal process every three years, similar to the current renewal process for Enrolled providers.

Providers that go through the Limited Enrollment process do not need to “register.” Registration should be reserved for the use of health plans to obtain Medicaid IDs for non-participating providers.

Limited Enrollment is an option for providers who will only be paid by a health plan. Providers who wish to submit claims directly to Florida Medicaid for fee-for-service reimbursement should apply for Full Enrollment.

No. Like Registered Medicaid providers, a Limited Medicaid provider cannot bill fee-for-service claims.

Registered providers are not required to seek Limited Enrollment but can choose to go through the Limited Enrollment process. By meeting the additional credentialing elements included within the Limited Enrollment process (such as background screening), providers may experience additional efficiencies when seeking credentialing by health plans.

Yes. Limited Medicaid providers can submit a new application to become an Enrolled Provider.

Contact the Provider Enrollment Contact Center for additional assistance at 1-800-289-7799, option 4.

Onsite visits, proof of education, training and work history will remain with the health plans along with any additional criteria as determined by the plans.