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Nursing Home Providers Must Submit Prior Auth for LTC Residents Starting October 1

Date: 09/25/25

Effective October 1, 2025, Sunshine Health will require nursing home providers to submit prior authorization requests for custodial and skilled services when a Sunshine Health Long Term Care (LTC) member resides in your facility. This is critical to ensure compliance with state requirements, and ultimately, that our members receive all needed services when they need it, regardless of setting.

Nursing home providers will be required to comply with this new policy to ensure payment for services. Providers must submit a prior authorization request via the Sunshine Health Secure Provider Portal or by faxing the request to 1-844-416-8319 for the service codes listed below.

Service Codes
Nursing Facility Services Billing CodesTherapy Service Billing Codes
*Medicaid Primary Only

Revenue Code

Description

Description

0101

Long Term Care Days

Physical Therapy

0185

Hospital Leave Days (Bed Hold)

Occupational Therapy

0182

Home Leave Days (Therapeutic Leave Days) (Bed Hold)

Speech Therapy

 Respiratory Therapy

Important Reminders

As of October 1, 2025:

  • New Requests: New service authorization requests and authorization renewals must be submitted via the Secure Provider Portal or faxed to 1-844-416-8319.
  • New Admissions: A completed Pre-Admission Screening and Resident Review (PASRR) form (PDF) is required and must be included with prior authorization request for new admissions.
  • Members With Recent Claims: For members who are active with Sunshine Health prior to October 1, 2025 and have a recently submitted claim for 0101 – Long Term Care Days in July 2025, Sunshine Health will create the initial authorization approving services for 12 months. Within 30 days prior to the authorization expiration date, you must submit a new authorization request via the Secure Provider Portal or by faxing it to 1-844-416-8319.
  • Bed Hold Days: If your facility is at 95% capacity and the member goes to the hospital, you should submit a prior authorization for bed hold days via the Secure Provider Portal or by faxing it to 1-844-416-8319.
  • Member Moves: If a member moves, leaves your facility for more than eight days, or expires, please notify Sunshine Health by calling 1-866-796-0530 Monday to Friday from 8 a.m. to 8 p.m. Eastern.
  • Please note: Service claims submitted without approved prior authorization will be denied.

Provider Portal Instructions

Frequently Asked Questions (FAQ)

Long-Term Care Skilled Nursing Facility Member Authorization Requirements, Effective October 1, 2025  

This FAQ guide helps providers understand the new Long-Term Care (LTC) authorization requirement for members living in skilled nursing facilities (SNFs), effective October 1, 2025. It answers common questions about the prior authorization process for claims and requests, and outlines different scenarios SNF providers may encounter when submitting authorizations for Custodial and Skilled Services.

  • Why are LTC Custodial authorizations being implemented?
    • Sunshine Health is implementing LTC SNF Custodial prior authorizations to align with authorization requirements for other LTC provider types, to ensure compliance with state requirements, to better track members and member locations, and for improved claims experience for providers.
  • Is this change for MMA, DSNP or just the LTC line of business?
    • The change is for the LTC line of business (LOB) only. The MMA process will remain in place and will continue to follow the 120-day requirements. The DSNP authorization process will remain in place and will continue to follow that process for the Wellcare line of business.
  • Is there a timeframe to submit the LTC Custodial authorization requests?
    • Sunshine Health will create authorizations for members already residing in SNFs prior to October 1, 2025. Providers will receive a faxed spreadsheet by the end of September listing all authorized members, including the authorization numbers and date spans.
    • Starting October 1, 2025, providers must submit authorization requests for all new Custodial members within 5 calendar days of member’s admittance under the LTC benefit. If a member’s LTC eligibility is not available from the regulatory agency upon a Custodial admission, then the authorization request must be submitted within 5 calendar days of when the LTC eligibility is made available by the regulatory agency. Providers are expected to monitor the DCF provider portal and AHCA web portal for ICP approval and Sunshine Health LTC ICP plan enrollment.
  • What is the turnaround time to receive the authorization and how will the facility be notified?
    • Providers will receive authorization letters via fax within 5 calendar days of Sunshine Health receiving a valid request.
  • Do skilled patients where Medicare is primary need authorization?
    • No, Sunshine Health does not require an authorization for Medicare primary skilled services. If Medicaid is primary, authorizations for skilled services will be required and providers should request skilled services authorizations from the MMA prior authorization team via fax at 1-866-796-0526.
  • If an MMA member transitions to LTC while in the SNF will the plan automatically create an LTC Custodial authorization for this member?
    • Yes, once the member becomes effective for LTC and is enrolled with Sunshine the plan will create the initial authorization approving Custodial services for 12 months.
  • Is Sunshine Health only approving the LTC SNF authorization if the PASRR is provided?
    • Sunshine Health requires a PASRR and the DCF NOCA for Room & Board to pay nursing home claims. Providers must submit a completed PASRR and the DCF NOCA for Room & Board along with the authorization request for the initial authorization. Sunshine Health will not accept authorization requests without these documents. For incomplete authorization requests, Sunshine Health will notify the provider via fax that additional information is required. Providers must resubmit authorization request with all required documentation for the authorization to be processed.
  • Will LTC authorization requests be approved for recipients with non-ICP Medicaid benefits plans such as the MWA (wavier) plan?
    • Yes, authorizations will be approved for recipients with non-ICP Medicaid benefit plans, such as the MWA (waiver). Providers must confirm the member’s Medicaid eligibility. If, upon SNF admission, the member is not listed as eligible for LTC ICP Medicaid in the Florida Medicaid Management Information System (FLMMIS), the provider should work with DCF and the member’s authorized representative to update the coverage from MWA (Community) to ICP (Custodial).
    • Once Sunshine Health receives the LTC Custodial authorization request, we will review the member’s eligibility within FLMMIS and make a determination. Providers are expected to monitor the DCF provider portal and AHCA web portal for ICP approval and Sunshine Health LTC ICP plan enrollment.
  • Are providers expected to submit requests to renew authorizations, or will Sunshine Health renew the authorizations automatically?
    • Providers must submit a new authorization request within 30 days before the current authorization expires by faxing it to the LTC UM Review team at 1-844-416-8319. We expect the provider portal will support LTC SNF authorization requests by the renewal timeframe.
  • Will the provider portal have the authorization term date listed in preparation for renewal authorizations?
    • The provider portal for requesting and viewing LTC Custodial authorizations is currently pending implementation. Until further notice, SNF providers will fax the LTC Custodial authorization request to the LTC UM Review team at 1-844-416-8319.
    • Authorizations will be built for 12 months and will have a start date and end date, according to LTC SNF authorization request and in consideration of member eligibility spans.
    • For the initial authorization Sunshine Health is creating for all LTC Custodial members leading up to October 1, 2025, we will fax authorization details in a spreadsheet, including the authorization end date to providers.
  • Will bed holds require a separate authorization request?
    • Yes, bed holds will require a separate authorization request. If the LTC Custodial authorization has expired prior to the member’s return to the facility, a new authorization request will be required.
    • Provider must send an updated PA form, hospital discharge paperwork and updated PASRR (if applicable) to LTC UM fax 1-844-416-8319 to request a re-authorization when member returns to the SNF.
  • What is the timeframe to request bed hold authorizations? How will providers request bed hold authorizations?
    • Bed hold requests are required within 5 calendar days from the date member discharged. Please submit bed hold authorizations via fax at 1-844-416-8319.
  • Will the providers need to include authorization number when billing claims? How will Sunshine Health provide the authorization numbers?
    • Yes, providers will need to include authorization numbers on claims. Sunshine Health will create authorizations for existing members residing in SNFs prior to October 1, 2025. Providers will receive authorization notifications via fax with a spreadsheet for all authorized members, including the authorization numbers, date spans, etc.
    • For SNF authorizations created after October 1, 2025, providers will receive authorization notifications for each member via fax. Authorizations will be approved for 12 months based on member LTC eligibility.  
  • Can bed hold charges be submitted on the Custodial claim?
    • Yes, bed hold charges can be submitted to Sunshine Health on the same claim as custodial charges.
  • What is the process if the providers are not at 95% capacity and do not meet the criteria for billing bed hold days? Will these authorizations be denied? How are providers that are not at 95% capacity supposed to notify Sunshine Health of temporary discharges (e.g., to the hospital)?
    • SNF bed hold requests will be reviewed by Sunshine Health upon submission by the SNF. Sunshine Health may request documentation demonstrating facility capacity is at or above 95% on a case-by-case basis. If the request does not meet the criteria for bed hold, it may be denied.
    • If a bed hold is not being requested, please notify SH LTC UM of the admission/discharge via fax at 1-844-416-8319 or email at LTC_Authorization_Inquiry_Box@centene.com with subject line “Nursing Facility Request.”
  • Are providers required to notify Sunshine Health of discharges to the community, discharges to Hospice, member expiration, or other changes in member’s status? If so, how do providers notify Sunshine Health?
    • Yes, providers should notify Sunshine Health of all discharges, including discharges to the community, and of all changes in member’s status, such as expiration. Please notify Sunshine Health’s LTC UM team of discharges or changes in status via fax at 1-844-416-8319 or email at LTC_Authorization_Inquiry_Box@centene.com with subject line “Nursing Facility Request.”
  • Will there be guidelines, documentation, or a process in writing for retro payments?
    • Sunshine Health is creating a SNF Quick Reference Guide that will be provided to SNF providers. Claims are reviewed and adjudicated based on provider claims submissions and meeting claims processing guidelines. The provider must ensure that approved LTC SNF authorizations, member DCF NOCA for Room & Board, and PASRR have been provided to Sunshine Health and that claims are submitted correctly to Sunshine Health.
  • Can you confirm the fax numbers to submit LTC Custodial authorization requests?

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