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Early Step Intervention Services (EIS) Quick Reference Guide (QRG)

Contact Information, Provider Help and Resources

Sunshine Health covers Early Intervention Services (EIS) and Child Health Services Targeted Case Management (TCM) for members receiving services through the Early Steps program. EIS provides for the early identification and treatment of recipients ages 3 years old and under with developmental delays or related conditions. EIS promotes a parent-coaching model intended to support the child in meeting certain developmental milestones. Positive early learning experiences are crucial for later success in school, the workplace, and the community. Research shows that the earliest experiences of children play a critical role in brain development. Infants and toddlers are assessed based on developmental skills to determine eligibility: physical, cognitive, communication, social-emotional and adaptive.

This Quick Reference Guide (QRG) covers the following products:

  • Sunshine Health Medicaid (MMA)
  • Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP)
  • Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI)
  • Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV)
  • Children’s Medical Services (CMS) Health Plan

Utilize these methods to verify member eligibility. These suggestions are not a guarantee of coverage.

  • Verify member eligibility by using the Sunshine Health Secure Provider Portal.
  • Using the portal, any registered provider can quickly check member eligibility using two datasets:
    • The member’s date of service, member name and date of birth
    • The member’s Medicaid identification number and date of birth
      • Note: The correct plan type must be selected

Coordination of Benefits

  • Member Coordination of Benefits (COB) information can also be found via the Secure Provider Portal.
  • Providers can also call Provider Services at 1-844-477-8313. Be prepared to share the member’s name and date of birth or the member’s Medicaid identification number and date of birth.

For all newly enrolled members, Sunshine Health allows for a Continuity of Care (CoC) period for EIS and EIS TCM services, as well as for other services that the member received prior to enrolling with Sunshine Health.

CoC period:

  • 120 days for MMA, CWSP, SMI, HIV and CMS members

This means that a provider can bill Sunshine Health for EIS and EIS TCM services that a new member was receiving — prior to enrolling in Sunshine Health — without having a contract in place. Sunshine Health will pay the Medicaid Fee for Service (FFS) rate for these services unless the provider was paid more. Sunshine Health will pay the higher amount for the first 30 days.

  • Sunshine Health’s system has been set up to pay all EIS and EIS TCM claims after the CoC period.
  • EIS services do not require authorization, but a copy of the Individual Family Support Plan (IFSP) should be emailed to: sun_ifsp@centene.com.

Prior authorization (PA) is required for certain services. To determine which services require authorization, please refer to our Pre-Auth Check Tool.

Sunshine Health

Use Sunshine Health’s secure portal to check a member’s eligibility, verify benefits, submit a referral to Case Management, submit claims, submit claim reconsiderations, etc.

Availity Essentials

Many of the same functions described above can be completed using the Availity portal. We will inform providers when new functionalities are released.

Prior-authorization requests are processed by Sunshine Health’s Utilization Management (UM) Department. To determine which services require authorization, please refer to our Pre-Auth Check Tool.
Standard Hours of Operation: Monday to Friday from 8 a.m. to 8 p.m. Eastern.

  • Weekend and After-Hours on Call-Numbers: 1-844-477-8313.
  • Medical Fax: 1-866-796-0526
  • Pharmacy Services Fax: 1-833-546-1507
  • Standard requests: Determination within five calendar days of receipt of request.
  • Urgent requests: Please call 1-844-477-8313. Urgent requests are made when the member’s physician believes that waiting for a decision under the standard timeframe could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy.

Our Case Management team can be reached Monday to Friday from 8 a.m. to 8 p.m. via the phone numbers below. For after hours or weekend assistance, use option 7.

Sunshine Health (Medicaid)

Sunshine Health Payer ID: 68069

Covered Services

  • Screenings
  • Initial Evaluations
  • Follow-Up Evaluations
  • Individual Sessions
  • Group Sessions

Medicaid may reimburse for services under the EIS program for Florida’s infants and toddlers from birth to 36 months of age who have EIS services authorized in their Individualized Family Support Plan. For more information about covered services, visit the AHCA Early Intervention Services (EIS) resource.
Description of the Specialty: EIS provides for the early identification and treatment of recipients ages 3 years old and under with developmental delays or related conditions. EIS promotes a parent-coaching model intended to support the child in meeting certain developmental milestones.

Targeted Case Management for EIS Members

Listed below are the Early Intervention Targeted Case Management codes and modifiers. Please be sure to include the applicable modifier on your claim or the claim may be denied.

  • These claims are considered behavioral health claims and should be submitted to the behavioral health payor ID via the claims’ addresses noted below.

Process for Claims Reconsiderations and Disputes

  • All requests for corrected claims or reconsiderations/claim disputes must be received within 90 days from the date of the original explanation of payment or denial. Providers have the option to file a second-level reconsideration/claims dispute. Second-level requests must be received within 90 days from the date indicated on the decision correspondence from the first-level request.
  • Quick Tip: Reconsiderations can be submitted via the Sunshine Health Secure Provider Portal in response to an underpaid or denied claim. Providers will know this option is available when the Reconsider Claim button appears within the Claims Details screen.

Electronic Claims Submissions

Electronic claims can be submitted via the Secure Provider Portal or the EDI clearing houses listed. The names and contact information to set up accounts with a clearing house are:

Paper Claims Submission

Medical Claims

Sunshine Health
Attn: Claims Department
PO Box 3070
Farmington, MO 63640-3823

Note: Clean Claims must contain the correct CPT billing code and modifier when appropriate. Additionally, the claim should contain the National Provider Identifier (NPI) and Correct Taxonomy Code.

Billing: The following codes are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply subscriber coverage or provider reimbursement. The codes listed below are not a complete list. Please refer to your Sunshine Health contract to determine all contracted/covered codes for each membership group.

Florida Medicaid Early Intervention Services Fee Schedule

Code

Mod 1

Mod 2

Description of Service and Limits

Maximum Fee

T1023

 

 

Screening (Maximum 3 per child)

$53.98

T1024

GP

UK

Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by a Physical Therapist (Maximum 1 per lifetime per child)

$40.49 30-minute unit (Maximum 4 units)

T1024

GN

UK

Initial Interdisciplinary Psychosocial and  Developmental Evaluation rendered by a Speech Therapist (Maximum 1 per lifetime per child)

$40.49 30-minute unit (Maximum 4 units)

T1024

GO

UK

Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by an Occupational Therapist (Maximum 1 per lifetime per child)

$40.49-minute unit (Maximum 4 units)

T1024

TL

 

Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by a Licensed Early Intervention Professional (Maximum 1 per lifetime per child)

$40.49 30-minute unit (Maximum 4 units)

T1024

HN

UK

Initial Interdisciplinary Psychosocial and Developmental Evaluation rendered by an ITDS (Maximum 1 per lifetime per child)

$29.96 30-minute unit (Maximum 4 units)

T1024

GP

TS

Follow-up Psychosocial and Developmental Evaluation rendered by a Physical Therapist (Maximum 3 per calendar year per child)

$40.49 30-minute unit (Maximum 4 units)

T1024

GN

TS

Follow-up Psychosocial and Developmental Evaluation rendered by a Speech Therapist (Maximum 3 per calendar year per child)

$40.49 30-minute unit (Maximum 4 units)

T1024

GO

TS

Follow-up Psychosocial and Developmental Evaluation rendered by an Occupational Therapist (Maximum 3 per calendar year per child)

$40.49 30-minute unit (Maximum 4 units)

T1024

TL

TS

Follow-up Psychosocial and Developmental Evaluation rendered by a licensed Early Intervention professional (Maximum 3 per calendar year per child)

$40.49 30-minute unit (Maximum 4 units)

T1024

TS

 

Follow-up Psychosocial and Developmental Evaluation rendered by an ITDS (Maximum 3 per calendar year per child)

$29.96 30-minute unit (Maximum 4 units)

T1027

SC

 

Early Intervention Individual Session Provided by an EIS professional (Maximum 1 hour per day)

$13.50 15-minutes (Maximum 4 units per day)

T1027

TT

SC

Early Intervention Group Session Provided by an EIS professional (Maximum 1 hour per day)

$6.75 15 minutes (Maximum 4 units per day)

 

Child Health Targeted Case Management Services Fee Schedule

Code and Modifier

Description of Service and Limits

Maximum Fee

T1017 TL

Targeted Case Management for Children’s Medical Services Early Steps Providers

$9.30 per unit

T1017 SE

Targeted Case Management for Children’s Medical Services Medical Foster Care Contractors

$9.30 per unit

PLEASE NOTE: Effective April 1, 2020, EIS Physical Therapy, Occupation Therapy & Speech Therapy should bill the 90,000 code range with TL Modifier.

Important Links

Claim Payment Disputes

This includes untimely filing, incidental procedure and unlisted procedure code.

Sunshine Health
Attn: Adjustments/Reconsiderations/Disputes
P.O. Box 3070
Farmington, MO 63640-3823

Provider on Behalf of Self – Medical Appeals

Providers can request an appeal for the following types of denials:

  • No authorization claims denials.
  • Authorization denials due to member not meeting medical necessity authorization denials and medical necessity, in addition to, benefits exhausted and non-covered procedures.

Sunshine Health
Attn: Adjustments/Reconsiderations/Disputes
P.O. Box 3070
Farmington, MO 63640-3823

For more information about the process, visit the Medicaid Member and Provider Appeals Processes Guide

Overpayment Refund Address

When a facility, group or practice identifies an overpayment, a refund should be sent to the address below and include all applicable claims for which the refund is being submitted.

Sunshine Health
Attn: Centene Mgmt. Co - Sunshine State Health Plan
P.O Box 947986
Atlanta, GA 30394-7986

If you are currently receiving paper checks and would like to switch to Electronic Funds Transfer (EFT), please register with Payspan.

Contact Payspan via the following channels:

Note: If your address is incorrect in PaySpan, please update it using the Provider Demographic Updates Tool or by calling Provider Services at 1-844-877-8313.

For more information, reach out to the PEAM overseeing your region.

  • Regions A, B: Email Provider Engagement Account Manager Beulah S. Simmons 
  • Regions C, D, E: Email Senior Provider Engagement Account Manager Sylvia Allen
  • Regions F, G, H, I: Email Provider Engagement Account Manager Frederick McCoy 

We encourage providers to keep their demographic information up-to-date using our online tool.

Providers can use our online tools to add a new practitioner or facility, start the credentialing process or update your Affiliated Providers (LOAP)/Practitioner Roster.

Enrollment Tools

Credentialing Tools

Note: Practitioners should not begin servicing Sunshine Health members until they have received a Provider Enrollment Confirmation letter from Sunshine Health’s Provider Enrollment department. Our enrollment process can take up to 60 days to complete. We will not backdate effective dates due to services provided ahead of the practitioner’s enrollment.

Provider Terminations

Providers can use the Provider Demographic Updates Form to submit these requests.

Contact Information, Provider Help and Resources

Medicaid (MMA)

  • Provider Services: All Products      
    • Call: 1-844-477-8313 (All products)        
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern
  • Pharmacy Services: All Products
    • Call: 1-800-460-8988, option 2    
    • Hours: 24 hours a day, 7 days a week
  • Member Services: MMA & SMI
    • Call: 1-866-796-0530        
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern
  • Member Services: CWSP
    • Call:1-855-463-4100       
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern
  • Member Services: HIV      
    • Call: 1-866-796-0530
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern
  • Member Services: CMS
    • Call: 1-866-799-5321
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern

Learn about our Provider Engagement Account Managers (PEAMs) and how they can help you and your practice. Our teams are regionally based and directly engage with parents and providers in the community. Our PEAMs can meet with you in-person or virtually to assist with a variety of services designed to support you and your child’s success. The following channels will help you contact Sunshine Health and stay informed about the latest policies, procedures and news:

The Nurse Advice Line can assist providers with checking member eligibility. It can also connect members to telemedicine for urgent care visits. Hours of operation are 24 hours a day, 7 days a week.

  • MMA/LTC/HIV: 1-866-796-0530 and follow prompts for Nurse Advice Line, then option 1, option 3 and option 7.
  • CWSP: 1-855-463-4100 and follow prompts for Nurse Advice Line, then option 1, option 2 and option 7.
  • CMS: 1-866-799-5321 and follow prompts for Nurse Advice Line, then option 1 and option 7.

If you are struggling with alcohol or drug use, experiencing ongoing anxiety or depression or undergoing a crisis, contact the 988 Lifeline using the options most convenient to you. Services are confidential, free of charge and available 24/7, 365 days a year.

Training

Sunshine Health offers a wealth of training opportunities. Providers and their staff can register for our live Provider Town Halls, which are held virtually and in-person; view videos of past webinars; or take self-paced online classes.

Telehealth

Members have 24/7 access to receive services virtually through our telehealth vendors below. Providers may furnish and receive payment for covered, eligible telehealth services in accordance with this policy and the provider’s scope of practice.

Telehealth Guide & Best Practices

Access and Availability Timeframe Standards

Sunshine Health establishes and assesses provider compliance with appointment wait times for various types of visits. View Access and Availability Timeframe Standards to find the guidelines that apply to your organization.

Find A Provider (FAP) Tool

The Find a Provider Tool tool can help members find a specialist or facility. Search by provider name, National Provider Identifier (NPI) and specialty type.

Community Resources

Sunshine Health Connects links members and caregivers in need with local programs and support.

Vendors 

Visit Vendors to find subcontractors and vendors and how to contact them.