FAQs

Can I check member eligibility online?
Yes, you can look up the eligibility of your patients by entering the patient name, date of birth or Medicaid I.D. or other search criteria to get instant eligibility search results. You can find out more, including eligibility history, member details and Primary Care Provider (PCP) details, by clicking on the member’s name.

Is it possible to search for a list of patients by provider?
A patient list search is now an option under the Eligibility tab. This expanded function lets you find out and sort patient details by name, I.D., SSI, gender, date of birth, age, address and/or provider name.

Is it possible to confirm the status of a submitted claim online?
You may confirm the status of your submitted claims through our new online claims search feature. Just enter your search criteria to find out if a claim has been paid, is set to pay or is still pending. You can also see a full description of your claims status, including what the payment amount was, the date it was paid and the claims check number.

Does Sunshine State Health Plan’s website offer secure messaging so that I may get my questions answered online?
Yes, providers and their representatives may communicate directly with us via secured e-mail.  It’s fast and it’s available seven days a week, 24 hours a day. You can ask us questions about your claims status, including adjustments and lost checks.

Can I search for other providers, including specialists, online?
Yes, you can search for providers and specialists by using our electronic Provider Directory. Look for doctors or medical facilities by entering your starting address and preferences for distance, gender, language and specialty.

What if I get an error message or can’t find the results I’m looking for?
The Sunshine State Health Plan website will redirect you back to the page where you started so that you can try again using different criteria. If you continue to have trouble, you may e-mail us directly using our secured e-mail messaging.

When are authorizations required?
Authorizations are required for certain services/procedures that are frequently over or under utilized or services indicating a need for care management. Authorizations must be requested before the services are rendered.

What is the difference between referrals and authorizations?
A referral is requested from provider to provider and an authorization is a request from a provider to provide certain services to a patient.

Who can obtain authorizations?
Primary Care Physician’s must obtain authorizations for certain services. Specialists may obtain authorizations once the Primary Care Physician has given a referral to the Specialist.

How are authorizations obtained?
There is no paperwork involved! Primary Care Physician or Specialists must initiate authorization of non-emergency services at least ten working days prior to the requested date of service. The Primary Care Physician simply calls Medical Management at 1-866-796-0530, and a referral specialist will enter demographic information then transfer call to a nurse for completion of medical necessity screening. If a provider is unable to request prior authorization at least ten business days in advance due to the nature of the member’s condition, an authorization request must be initiated ASAP.