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Continuation of Benefits Recovery Process Following Adverse Medicaid Fair Hearing Decisions

Date: 09/04/26

Sunshine Health is implementing a process for cases involving continuation of benefits during the Medicaid appeal and fair hearing process.

Under the Medicaid Fair Hearing provisions of the AHCA SMMC Contract, if a member receives continued services during the appeal process and the final hearing decision upholds Sunshine Health’s action, Sunshine Health may seek recovery of costs for services furnished during the requested continuation of benefits period.

What This Means for Providers

  • Providers should continue furnishing authorized services while continuation of benefits remains in effect.
  • Providers should continue submitting claims in accordance with normal billing procedures.
  • Providers must not delay, reduce, or deny authorized services based on a potential future recovery.
  • If recovery is pursued after a final adverse hearing decision, Sunshine Health will send written notice to the provider and the member and will follow its standard recovery procedures. The notice will explain who Sunshine Health is seeking recovery from and the applicable next steps.
  •  Providers should not seek payment from the member unless permitted under applicable Medicaid requirements and Sunshine Health’s provider agreement.

Questions regarding specific cases may be directed to the Appeals and Grievance Department using the contact instructions included in the applicable notice.

Thank you for your partnership and continued commitment to serving our members.

Questions?

Sunshine Health has a wealth of resources available to help answer your questions and address your concerns:

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