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Q3 2024 Connected In Care

 

Sunshine Health reminds providers that AHCA has set important enrollment and billing requirements that they must follow as Medicaid providers.

We put together a guide to help providers check AHCA’s provider data reports; how to check their own National Provider Identification (NPI) and Medicaid ID numbers; and how to identify, understand and fix denial codes: Provider Guide: AHCA Rules For Medicaid Enrollment, Billing

Sunshine Health updated the list of Medicaid Prior Authorization changes, but we’re holding off on changing the Behavioral Health codes.

The updated physical health codes took effect on September 1, 2024. But we did not implement the Behavioral Health code changes we previously shared with providers in a July 31 email. We are re-evaluating those codes and will update providers in the coming months.

Sunshine Health requires Prior Authorization (PA) as a condition of payment for many services. The following notice contains information regarding such prior authorization requirements and is applicable to all Medicaid products offered by Sunshine Health.

Visit Sunshine Health Medicaid Prior Authorization Changes to view the updated codes and learn more about the PA changes.

Wellcare is offering Primary Care Physicians (PCPs) an enhanced payment of $20 for every flu shot they administer to members this fall.

The program started October 1, 2024 and runs through December 31, 2024.

PCPs must submit detailed claims for each patient visit related to the Centers for Medicare & Medicaid Services (CMS) Star measure: annual flu vaccine. Claims must be received by February 28, 2025 and then a one-time payment will be sent out in March 2025.

Wellcare 2024 Enhanced Payment for Influenza Vaccine Codes

The Wellcare by Allwell Medicare Advantage plan in Florida will be consolidated into the Wellcare Medicare Advantage plan in Florida effective January 1, 2025. Wellcare made this decision after a comprehensive review to best align our network strategy and resources. We are currently notifying members about this change.

We are committed to making this transition as smooth as possible for our providers and their patients. If you currently participate in our Wellcare plan, much of this will already be familiar.

What’s Changing

What’s Not Changing

  • Your contract with Wellcare will remain valid and no action is needed to maintain it
  • Member ID cards
  • Your Provider Engagement Account Manager

Sunshine Health has revamped the way providers can access and check appointment scheduling standards online.

The Agency for Health Care Administration (AHCA) sets standards for scheduling appointments for medical services and behavioral health services. Those standards are designed to help providers and their staff provide the best care possible to your patients, our members.

Visit Sunshine Health’s Manuals, Forms and Resources page and scroll down to Standards for Appointment Scheduling to find the health plan standards you need.

Providers can also directly access each health plan appointment standards they need:

Sunshine Health wants to ensure providers understand the definition of Expedited/Urgent Authorization requests. Expedited/Urgent Service Authorization assignments are defined as requests that, if considered in a standard timeframe, could jeopardize the health or life of a member.

Submitting non-urgent requests as urgent can cause delays in processing as it floods our inventory with reviews that may not need urgent priority. Knowing when to submit expedited/urgent requests and being proactive in your requests can help reduce delays in authorizations for all the care your patients need.

This resource can help providers know when and when not to submit Expedited/Urgent Authorization Requests: Expedited/Urgent Authorization Requests Explained Tip Sheet

Sunshine Health recently updated the Outpatient Authorization Form. In fact, we are constantly updating and improving the manuals, forms and other materials and resources that providers rely on to serve their patients and work with the health plan.

Those resources can be found in one place: Manuals, Forms and Resources.

Sunshine Health changed how hourly Personal Care Services (PCS) and Private Duty Nursing (PDN) services are authorized and communicated via HHAeXchange, our electronic visit verification portal.

These changes took effect on October 21, 2024.

Our goal is to eliminate early consumption of authorized hours and ensure our members receive the services they need without interruption. This also enhanced our PDN/PCS staffing options.

Learn more about Authorization Creation Changes for Personal Care Services (PCS)/Private Duty Nursing (PDN) services

Sunshine Health is offering providers the opportunity to take part in training aimed at breaking down racial and ethnic disparities that impacts maternity care for pregnant women and their babies before, during and after pregnancy.

The March of Dimes’ virtual training entitled Awareness to Action: Dismantling Bias in Maternal and Infant Healthcare™ is designed to help providers recognize and remedy implicit bias. It’s a self-paced online course, so providers and their staff can take it whenever it’s convenient for them.

Learn more about March of Dimes Implicit Bias Training.

 

Sunshine Health gives members and providers the right to appeal decisions that affect their care and services. To help navigate this process, we created a guide to explain the differences and similarities between the member and provider appeal process.

This will help medical professionals and their patients understand the key steps, timelines and requirements for filing their respective appeals. And it will help providers better advocate for their patients — and help members better advocate for themselves. Download the Medicaid Member and Provider Appeal Processes FAQ (PDF)

This and other guides can be found on our Resources for Home Health Providers page.

AHCA allows members to receive 120 days of custodial nursing home coverage. Sunshine Health is offering training for providers to learn more about this state-mandated nursing facility (NF) benefit. Join us for a live webinar or self-paced online training. Choose the training options that are most convenient for you and your staff.
Register now for the Zoom webinar that is convenient for you.Providers only need to attend one session, and trainers will answer their questions. All sessions start at 8 a.m. Eastern:

  • November 14, 2024
  • December 12, 2024
  • January 9, 2025
  • February 13, 2025
  • March 13, 2025
  • April 10, 2025

Sunshine Health thanks providers for all you do to help keep our Medicaid members healthy and ensure they receive assistance for their Social Determinants of Health (SDOH).   

To show our appreciation for your efforts, Sunshine Health is offering additional reimbursement to providers who submit detailed claims or encounters using Social Determinant of Health ICD-10-CM Z-codes. Learn more about SDOH Enhanced Payments

The address for providers to mail refunds for overpayment to Sunshine Health (MMA, CWSP, SMI, LTC), Ambetter from Sunshine Health and Children’s Medical Services (CMS) Health Plan has changed.

When your practice identifies an overpayment, please include the reference number to the claim or the claims tied to that refused and use this address:

Centene Mgmt. Co. - Sunshine State Health Plan
P.O Box 947986
Atlanta, GA 30394-7986

Please do not use the Orlando P.O. Box. Anything mailed to the previous address will be returned to sender as undeliverable.

Sunshine Health’s updated Hospice Provider Quick Reference Guide (QRG) is now available online to help you understand the policies and procedures for your specialty area.

This update clarifies that the health plan will now pay the higher rate for all the days billed on the claim line. 

Ambetter from Sunshine Health wants to help Home Health (HH) and Durable Medical Equipment (DME) providers properly submit outpatient Prior Authorization (PA) requests for our members. We put together a quick reference guide (PDF) to help take you through the process. 

We created an online resource to help HH/DME providers address all their issues. To find the reference guides, forms and information you need, visit our Resources for Home Health Providers page.

 

Children’s Medical Services (CMS) Health Plan Wrap Up

Children’s Medical Services (CMS) has added provider training sessions in Applied Behavioral Analysis (ABA) services for children with autism spectrum disorders.

Visit Provider Training and scroll down to the Applied Behavioral Analysis section to access the training materials.

Providers can now view the revamped CMS Health Plan Standards for Appointment Scheduling via a dedicated web page.

These standards are set by AHCA and determine how many days or hours your practice has to schedule appointments with members seeking urgent care, a routine check-up or follow-up visit, and also limits how long members should wait on the phone to make appointments.