LTC Frequently Asked Questions
AHCA has the lead on the entire SMMC program and will contract with the health plans for the delivery of SMMC long term care services. Additionally, DOEA is responsible for monitoring quality assurance components.
DOEA’s CARES program will remain responsible for determining medical eligibility (i.e., level of care) for recipients wishing to enroll in the new program. Call Provider Services at 1-844-477-8313 for specific locations and phone numbers.
Visit our Become a Provider page or call Provider Services at 1-844-477-8313 Monday through Friday from 8 a.m. to 8 p.m. Eastern.
The enrollee can reach out to Choice Counseling at 1-877-711-3662 if they to choose to enroll in another health plan. Existing services for eligible enrollees will continue for up to 60 days OR until the recipient receives a comprehensive assessment and a new plan of care is developed.
You should contact your case manager any time a Sunshine Health enrollee moves in or out of your facility, enters or is discharged from hospital care, or any other temporary or permanent change in living status. You can contact your case manager by contacting member services at 1-866-796-0530.
Prior authorization is required for all Long Term Care services except nursing facility room and board and ALF services. Enrollee needs for all non-skilled services must be requested directly from the enrollee/enrollee’s representative to the LTC case manager. Skilled service requests require prior authorization along with a prescription from a licensed physician and are processed through our Utilization Management Department via fax at 1-855-266-5275 or through the Secure Provider Portal.
Providers who are part of Sunshine Health’s network will be reimbursed for covered services, assuming the enrollee is eligible on the date(s) of service and services have been authorized prior to the service being rendered, according to the contracted fees. Enrollees should not be billed for covered services.
Sunshine Health has made it easy and convenient to submit claims directly to us on our Secure Provider Portal. Electronic claims can also be submitted via Electronic Data Interchange (EDI). EDI vendors are listed on the Providers Quick Reference Guide (PDF) or call Provider Services at 1-844-477-8313 for more information.
Submit claims for professional services and durable medical equipment on a CMS 1500. A UB 04 is the only acceptable claim form for submitting nursing home services. Incomplete or inaccurate information will result in the claim being rejected or denied for corrections.
Payments are expedited when claims are submitted electronically. Clean claims will be adjudicated (finalized as paid or denied) within twenty (20) days if electronically submitted (10 days for Nursing Homes) vs. forty (40) days when submitted on paper (only red originals will be accepted) from the receipt of the claim. All participating providers must submit claims within 180 days from service date.
Providers can also take advantage of direct deposit services through PaySpan. The process is easy and you may enroll for direct deposit by calling 1-800-733-0908 or you may register at payspanhealth.com. Providers can also check out our Quick Reference Guide (PDF) for more information.
Eligibility will be verified by Sunshine Health prior to issuing authorizations. Providers should verify eligibility for ongoing services via the Secure Provider Portal or by calling Provider Services at 1-844-477-8313 Monday through Friday from 8 a.m. to 8 p.m. Eastern.
Call Provider Services at 1-844-477-8313 Monday through Friday from 8 a.m. to 8 p.m. Eastern.
- Updates about the Statewide Medicaid Managed Care program are posted on the AHCA website.