Nursing Home Providers Must Submit Prior Auth for LTC Residents Starting October 1
Date: 07/30/25
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.
| Nursing Facility Services Billing Codes | Therapy 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
- To register for the Secure Provider Portal, visit the Login page.
- If you have questions or need support using the Secure Provider Portal, call Provider Services at 1-844-477-8313 Monday to Friday from 8 a.m. to 8 p.m. Eastern. You can also contact your Provider Engagement Account Manager (PEAM). To locate the account manager supporting your specialty and region, use the Find Your Account Manager tool.
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