Claim Concerns
Sunshine Health strives to resolve claim issues promptly and accurately. Providers are strongly encouraged to follow the appeal and reconsideration procedures outlined in the Provider Manual (PDF) when submitting requests.
If, after following these steps, further review is required, please complete the form below. Be sure to include all required information and supporting documentation, as incomplete submissions may cause delays. Please note, the review process can take up to 30 business days to complete. All claim reviews are subject to timely filing restrictions as detailed in our provider manuals and contractual agreements.
Claim Reconsiderations Related to Code Editing and Other Edits
Claim reconsiderations resulting from claim edits and medical record necessity must be handled through the provider claims reconsideration process described in the Provider Manual (PDF).
IMPORTANT NOTICE:
This form is intended only for claim-related matters.
- Requests to join our network are not processed using this form. To request to join our network or add a product to your existing agreement, please use our Network Participation Request Form. Once you have completed this form, please allow up to fourteen (14) days for our Contracting team to review your request.
- This form does not facilitate requests for ownership changes. To process a change of ownership of your entity, please visit our Change of Ownership Request Form.
- This form does not process any changes to member data. For member-related inquires, please login to the Member Portal.
- This form is not intended to add a new practitioner to an existing group. To add a new practitioner to an existing, participating group, please download our LOAP/Practitioner Roster Form (xlsm) and submit a Provider Enrollment Request.
For the specific inquiries listed below, please refer to the Secure Provider Portal or Provider Manual (PDF). You may also contact our Provider Services team at 1-844-477-8313, Monday through Friday, 8 a.m. to 8 p.m., for assistance with the following:
- First-time claim rejections
- Corrected claim requests
- Claims requiring medical record review
- Claim status
- Claim appeal/reconsideration status
- Authorization/coding appeal reviews
- General claim inquiries
Additional Assistance
Sunshine Health has a team of Field Provider Engagement Account Managers (PEAMs) throughout Florida who are committed to supporting providers and addressing your needs. These team members spend several days a week directly engaging with providers in the field focused on performance within our network and strategic initiatives and work in-house to support strategic initiatives and administrative duties.
To best serve your needs, please use our Find Your Account Manager tool to identify your designated PEAM. Our PEAMs are available via email or can meet with you in person or virtually to assist with a variety of services designed to support the success of your practice.
Submission Guidelines:
- Submit only one ticket per issue pertaining to the impacted claims
- Attach all applicable supporting documentation
- If the issue relates to a previous ticket (appeal/reconsideration), include the reference number
- The Claims Template (xlsx) is mandatory and must be submitted in its original Excel format. PDF submissions are not accepted and will not be processed.