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IT issue impacting claims payments for some CMS Health Plan members

Date: 01/20/22

Fort Lauderdale, Florida

We recently discovered an IT issue impacting claims payments for some Children’s Medical Services Health Plan members after Sunshine Health’s operation of the health plan began on October. 1, 2021.

We are diligently working to address the issue, and most of the impacted providers should have already started to receive payments for incorrectly rejected claims. The issue is related to claims adjudication differences in Sunshine Health and WellCare systems. Please note: Not all providers were impacted, even among similar provider types and claims, but issues include:

  • Sporadic member eligibility determinations for CMS members driving incorrect claims denials. This issue was corrected in our systems on December 19, 2021, and all impacted claims are scheduled to be reprocessed by the end of January. Most providers are already receiving payments for these claims. No action is needed by impacted providers.
  • Delayed authorizations impacting some home health providers is being addressed through additional staffing and system corrections. In the short-term, we opened up flexibility for impacted providers to bill the health plan directly. No action is needed by impacted providers.
  • Claims issues for therapy providers related to new industry standard edits. We removed this update in our system on January 11, 2022 and impacted claims have been reprocessed. No action is needed by impacted providers.

We apologize for any inconvenience this system migration error caused. We want you to know we are committed to timely and accurate claim payments, and are working diligently to correct this issue. We value your partnership and rely on the critical care you provide to our CMS members.

To better serve you, we created an enhanced provider claims resolution program where you can meet 1:1 with our Chief Operating Officer and Provider Services leaders to get live, customized support. Schedule an appointment now.

If you have any issues unrelated to claims, please contact your Provider Relations representative. If you don’t know your representative, please go to our Integration web page and scroll down to the “Find My Provider Relations Representative” link. In addition, any provider needing assistance can always call Sunshine Health Provider Services at 1-844-477-8313, 8 a.m. to 8 p.m. Eastern, Monday through Friday.

Bill Kruegel, Chief Operating Officer
Sunshine Health