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For Providers

Important Provider Updates

New Features in the Secure Provider Portal

Sunshine Health values our relationship with our provider partners and are pleased to announce an exciting new tool will be available April 1.

InterQual Connect™, will be available in our web authorization request process within our Secure Provider Portal. InterQual Connect (IQC) is an integrated medical review solution, enabling payers and providers to streamline the medical review process and eliminate redundant reviews.

A key component of meeting provider needs is our Secure Provider Portal, which enables providers to conduct business with Sunshine Health from the convenience of their desktops seamlessly and in real time.

Vaccine Coverage for MediKids Enrollees

Sunshine Health covers vaccinations for MediKids enrollees under the SMMC program. Services rendered in 2018-2020 will be paid at the applicable 2018 MediKids fee schedule or MPIP rate. Services rendered from 2021 forward will be paid at the current CDC vaccination rate. Any prior underpayments will be reprocessed automatically. Providers do not need to resubmit claims.  

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. New inpatient hospital claims require the initial date of admission, dates of service and amounts from previous claims through the current billing. The final replacement claim must be billed for the complete stay, from the first date of admission through the date of final discharge.

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.

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.

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.