Guidelines for proper claims submissions effective Oct. 1, 2021
Date: 08/31/21
Fort Lauderdale, Florida
Centene’s acquisition of WellCare's Medicaid products, including Staywell Health Plan, will be complete Oct. 1, 2021. Sunshine Health will also operate the Department of Health’s Children's Medical Services Health Plan beginning Oct. 1, 2021. WellCare Medicare products, claims and correspondence procedures are not changing at this time.
We value your partnership and want to help ensure proper claim submission to each plan based on the dates of service. We want your claim submissions processed as efficiently as possible. Electronic claim submission (EDI) is the preferred method for fast and accurate processing.
If you must submit paper claims, you must mail to the appropriate payer’s P.O. Box based on date of service guidance below. Failure to follow these instructions may result in eligibility rejections. Please review the guidance below and update your system accordingly.
Date of Service | Health Plan Name | Claim Type | Electronic Payer ID |
Before Oct. 1, 2021 |
Staywell Health Plan, Children's Medical Services Health Plan
|
Professional and Institutional | 14163 |
On or after Oct. 1, 2021 |
Sunshine Health, Children’s Medical Services Health Plan - Operated by Sunshine Health
| Professional and Institutional | 68069 |
How to determine the correct payer by date of service:
If billing a professional submission with services spanning before and after Oct. 1, 2021, please split the services into two separate claim submissions as outlined below.
- EDI: Professional (837P) service date for all claim lines is located in Loop 2400 (DTP*472*from-through~)
If billing a professional or an outpatient bill type institutional submission, please use the earliest “from” date in the claim submission as outlined below.
- EDI: Professional (837P) earliest service date in all claim lines is located in Loop 2400 (DTP*472*from-through~)
- EDI: Institutional statement date is located in Loop 2300 (DTP*434*from-through~)
If you have any questions, please contact the EDI Department at the email address below.
Date of Service | Health Plan | Provider Service Phone # | Questions via email |
| Before Oct. 1, 2021 | Staywell Health Plans, Children's Medical Services Health Plans | 1-866-231-1821 |
|
On or after Oct. 1, 2021 | Sunshine Health Plan, Children’s Medical Services Health Plan - Operated by Sunshine Health | 1-844-477-8313 |
We value our partnership and are here to help. The websites below provide information to help providers find answers.
Date of Service | Resource Links |
Before Oct. 1, 2021
|
|
On or after Oct. 1, 2021
|
|
Correspondence:
Your billing department will need to submit to the appropriate payer to prevent payment delays. Use the same date of service guidance on the first page to determine the correct payer.
Health Plan & Correspondence Type | Date of Service | Mailing Address |
| Claim Payment Disputes (related to untimely filing, incidental procedure, unlisted procedure code) | Before Oct. 1, 2021 | WellCare Health Plans
|
| Claim Payment Disputes (related to untimely filing, incidental procedure, unlisted procedure code) | On or after Oct. 1, 2021 | Sunshine Health Attn: Adjustments/Reconsiderations/Disputes P.O. Box 3070 Farmington, MO 63640-3823 |
| Claim Appeals (Medical) (Medical necessity, authorization denials, benefits exhausted and non-covered procedures) | Before Oct. 1, 2021 | WellCare Health Plans
|
| Claim Appeals (Medical) (Medical necessity, authorization denials, benefits exhausted and non-covered procedures) | On or after Oct. 1, 2021 | Sunshine Health Attn: Adjustments/Reconsiderations/Disputes P.O. Box 3070 Farmington, MO 63640-3823 |
Electronic Funds Transfer and Electronic Remittance:
There are no changes, as PaySpan® Health will continue to be the provider of Electronic Funds Transfer (EFT) and Electronic Remittance Advice/Explanation of Payment (ERA/EOP) free solutions. If you are not already registered, create a new account by registering at payspanhealth.com/ or call 1-877-331-7154.