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Behavior Analysis (BA) — Provider Quick Reference Guide

Continuity of Care (COC)

Sunshine Health coordinates BA services for all members new to our plan to ensure there is no interruption in care. Effective February 1, 2025, the continuity of care (COC) period for new Sunshine Health Medicaid members is 120 days from the date of plan enrollment.

After Effective Date of New Enrollment

  • Providers should continue providing all medically necessary services that were previously authorized, regardless of whether the provider is participating in the plan’s network. Sunshine Health will pay for previously authorized services for up to 120 days for Medicaid members and will pay providers at the rate previously received.
  • For existing authorizations with approaching end dates, submit requests to Sunshine Health starting January 16, 2025, for start dates February 1, 2025, and beyond.
  • During the transition of care, we will backdate a request up to 30 calendar days.
  • Sunshine Health will honor existing prior authorizations through May 31, 2025. If the pre-approved authorization extends beyond May 31, 2025, Sunshine will extend the authorization through July 31. 2025. This includes services provided by non-par providers. After the COC period ends, members must select an in-network provider and BA services will require prior authorization.
  • For enrollees that change plans during the initial continuity of care period, Sunshine Health will coordinate with the previous plan to ensure existing prior authorizations will be honored.

Methods for Claims Submission

For both paper and electronic data interchange (EDI) claim submissions starting February 1, 2025, the appropriate Center for Medicare and Medicaid Services (CMS) billing forms are required:

  • CMS 1450 (UB04) for facilities.
  • CMS 1500 for professionals.

There are several ways to submit claims:

Health Plan

Claim Type

Payer ID

Paper Claim Mailing Address

MMA, SMI, CWSP, HIV/AIDS and Comprehensive members

Professional and Institutional

68069

Attn: Claims Department
P.O. Box 3070
Farmington, MO 63640- 3823

Note: Please reference the vendor provider manuals for their payer IDs.

Billing

In general, Sunshine Health follows Centers for Medicare & Medicaid Services (CMS) billing requirements. Please refer to your contract to determine contracted products, negotiated rates and Fee Schedules. For additional questions, contact Sunshine Health Provider Services at 1-844-477-8313.

  • Clean claims will be adjudicated (finalized as paid or denied) at the following levels:
    • 50% of all clean claims submitted within 7 days.
    • 70% of all clean claims submitted within 10 days.
    • 90% of all clean claims submitted within 20 days.
  • Adjusted claims, requests for reconsideration and disputed claims will be finalized to a paid or denied status 30 calendar days of receipt.

Timely Filing Guidelines

  • Initial Filing: 180 calendar days of the date services were rendered.
  • Corrected/Reconsideration/Dispute/Coordination of Benefits: 90 calendar days from the payment/denial notification.

Important Links

Contact Information

If you have claims concerns, please email Provider Operations Senior Manager Sonya Frazier.

For other concerns, please reach out to your Provider Engagement Account Manager.