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For Providers

Important Provider Updates

Interim Billing Requirements

Starting Feb. 1, 2021, Sunshine Health requires hospital providers to use inpatient type of bill code 0112 interim when billing first-time claims for interim inpatient stays that exceed 100 consecutive days.

For each subsequent inpatient hospital billing, the previous interim claim is voided by being recouped and replaced with the new claim type of bill code 0117.

Questions regarding this update can be emailed to SunshineProviderRelations@Sunshinehealth.com.

Provider Coronavirus Information 

We are closely monitoring and following all guidance from the Centers for Medicare and Medicaid (CMS), the Florida Department of Health (DOH), the Agency for Health Care Administration (AHCA), and all other applicable agencies as it is released to ensure we can quickly address and support the prevention, screening and treatment of COVID-19. Read provider coronavirus guidance.

Diagnostic Testing Guidelines for 2019-Novel Coronavirus – COVID-19

It is the policy of health plans affiliated with Centene Corporation® that tests authorized under the FDA Emergency Use Authorization (EUA) for diagnosing COVID-19 are medically necessary when following the CDC guidelines for evaluation of persons under investigation for COVID-19. Read the clinical policy for Diagnostic Testing Guidelines for 2019 Novel Coronavirus – COVID-19 (PDF).

2021 Formulary Changes for Medicare Part D-DSNP and Medicare Part D-MAPD

On Jan. 1, 2021, some drugs will no longer be covered on our Medicare/Medicare-Medicaid formulary(ies). Please refer to the list of the most commonly prescribed drugs being removed along with the drug’s 2021 formulary alternative(s) to identify the appropriate options for your patients.

Behavior Analysis EVV Program Now Live for Fee-for-Service Regions 9, 10 and 11

Effective Dec. 1, 2020, providers in regions 9, 10 and 11 must bill for behavior analysis (BA) services through the Tellus Electronic Visit Verification (EVV) System. Those regions include the counties of Broward, Palm Beach, Miami-Dade and others.

Claims submitted through Florida Medicaid Management Information System (FMMIS) via the Medicaid Provider Web Portal will soon be denied. Providers should act now to ensure compliance and avoid potential payment delays. Details and other enforcement dates.

Medicaid Member Rewards - My Health Pays™

Members are rewarded for focusing on their health! They can earn My Health Pays™ rewards when they complete healthy activities such as a yearly wellness exam, preventive screenings and tobacco cessation coaching. 

Expanded Hepatitis A vaccine Medicaid benefit

Sunshine Health expanded coverage for the Hepatitis A vaccine for members ages 0-20 as medically necessary, and for members ages 21 and older with chronic liver disease or viral hepatitis infection. There is a maximum of two per lifetime. Please talk to your eligible patients about whether the vaccine is right for them.

FDA Medical Device Recall Notification for ResMed Stellar Ventilators

Effective immediately, Sunshine Health cautions all providers to discontinue use of ResMed Stellar Ventilators - Stellar 100 and 150 No-invasive and Invasive. These devices are used in hospitals, homes, or for mobile use with wheelchairs. The sound alarm in these devices may fail to work and may cause serious injuries or death. View the full notice.

Sunshine Health offers health insurance programs that fit the unique needs of our members.

View all of our available programs below. Select one to view more information and resources for our plan.