Change in Retrospective Review Process for Behavioral Health
Date: 08/01/19
Sunrise, Florida
Behavioral Health Providers: Thank you for your continued partnership with Sunshine Health. This notice is to inform you of changes to the retrospective review process for all lines of business (Allwell, Ambetter, Child Welfare, Healthy Kids and Medicaid) for behavioral health providers.
Effective November 1, 2019, Sunshine Health will not make retrospective review determinations for behavioral health services after the member is discharged or services have been completed. Sunshine Health will complete a retrospective medical necessity review when services are delivered without a prior authorization and/or if they did not meet timely notification to Sunshine Health for the following only:
- Inpatient admissions when the member is still hospitalized.
- Outpatient services when the patient is still receiving the outpatient services requiring authorization.
For situations not meeting the criteria above, Behavioral Health providers may submit the claim for processing, which will be denied as “services not authorized,” and may initiate the provider reconsideration and dispute resolution process after receiving the denied claim notice.
In situations in which a service does not meet medical necessity and the claim has been denied, providers may submit a redetermination request to Sunshine Health for a review of the denial along with supporting documentation to prove medical necessity.
All requests for claims reconsideration or adjustment must be received within 90 calendar days from the date of notification of payment or denial (please refer to the provider manual for information regarding qualifying circumstances). Submit claim reconsiderations or adjustments through our secure web portal or mail to:
Sunshine Health
Attn: Adjustments/Reconsiderations/Disputes
PO Box 3070
Farmington, MO 63640-3823
If you have any questions about this change, please don’t hesitate to reach out to Provider Services at 1-844-477-8313.