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Reminder: Do Not Submit Authorization Requests and Claims with Non-Billable Diagnosis Codes

Date: 10/07/24

Sunshine Health reminds providers to adhere to the Centers for Medicare & Medicaid Services (CMS) guidelines for ICD-10 diagnosis codes. Before providers request authorization requests or submit claims, they should utilize billable diagnosis codes to prevent authorization returns and/or claim denials.

Sunshine Health is committed to ensuring that authorizations are processed in a timely manner. These tools can help providers locate and utilize the correct codes:

Please note: The 2024 ICD-10-CM/PCS code sets codes became effective on October 1, 2023. All claims with a date of service on or after this date should use the 2024 codes.

Non-Billable Diagnosis Codes Will Result in Error Messages

Providers who submit authorization requests via the Secure Provider Portal with non-billable diagnosis codes will receive an error message and will be asked to resubmit the correct billable diagnosis codes.

Providers who fax an authorization request with non-billable diagnosis codes will receive a fax with the same explanation.

When providers submit claims, please list the appropriate billable diagnosis code in all the necessary areas — for example, in the primary, secondary, and tertiary places of the claim. This is important to help prevent claim denials for non-billable diagnoses.

Questions?

If you have any questions, please call Sunshine Health Provider Services at 1-844-477-8313 or visit the Secure Provider Portal. Our Provider Engagement staff can also answer questions. Visit the Find Your Account Manager tool to find who supports your specialty and region. Keep up with the latest Sunshine Health provider updates by reviewing and bookmarking Provider News.

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