Hospice Provider Quick Reference Guide (QRG)

Sunshine Health supports entities that provides a continuum of palliative and supportive care for the terminally ill patient and patient's family. That includes core services such as counseling services; medical social services; nursing services; physician services; and non-core services such as hospice aide services; durable medical equipment (DME) and medical supplies; pharmacy services; therapy services; volunteer services; and any item or services specified in the plan of care as reasonable and necessary for the palliation and management of the recipient’s terminal illness or related condition in accordance with 42 CFR 418.202. Providers should utilize this educational guide to supplement information outlined in our Provider Manual (PDF).

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)

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.

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

Prior-authorization requests are processed by Sunshine Health’s Utilization Management (UM) Department.

• Standard Requests: Determination within seven calendar days of receipt of request.
• Urgent Requests: Call 1-844-477-8313. Urgent requests are made when the member or their 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.
• Medical Fax: 1-866-796-0526
• Pharmacy Services Fax: 1-833-546-1507

Note: Find treatment and prior authorization forms via the Prior-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.

• Availity Portal: Availity Essentials

• Availity Client Services: If you need assistance, call 1-800-AVAILITY (1-800-282-4548). Assistance Monday through Friday from 8 a.m. to 8 p.m. Eastern.

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
  • Note: Find treatment and prior authorization forms via the Prior-Auth Check Tool.
• 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)

• MMA, SMI and HIV: 1-866-796-0530, option 2
• CWSP: 1-855-463-4100, option 2
• After Hours or Weekends, option 7

Member Referrals to Case Management 

Referrals can be submitted via the Secure Provider Portal under the “Referrals” tab of the Member’s Record. After successful submission, a message will appear confirming this.

Sunshine Health Payer ID: 68069

Important Links

• AHCA Hospice Coverage Policy (PDF).
• AHCA Provider Reimbursement Schedules and Billing Codes
• AHCA Hospice Room & Board Rates
• AHCA Hospice Regulations (AHCA)
• AHCA Hospice Coverage Policy (PDF) 
• Florida Department of Health License Verification
• Sunshine Health – Multiple Claim Submission Wizard (PDF)
• Sunshine Health Manuals, Forms and Resources

Note: Medicaid providers must follow the AHCA enrollment and billing requirements. For more information, consult the Provider Guide: AHCA Rules For Medicaid Enrollment, Billing.

Covered Services

The following services, included in the per diem payment, must be provided in accordance with 42 CFR 418.64:

• Counseling services
• Medical social services
• Nursing services
• Physician services

Non-Core Services

The following services, included in the per diem payment, must be provided when specified in the recipient’s plan of care and in accordance with 42 CFR 418.70-78 and 42 CFR 418.64:

• Hospice aide services
• Medical supplies and durable medical equipment
• Pharmacy services
• Therapy services
• Volunteer services
• Any other item or service specified in the plan of care as reasonable and necessary for the palliation and management of the recipient’s terminal illness or related condition in accordance with 42 CFR 418.202

Hospice Services in a Nursing or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)

Florida Medicaid reimburses providers for nursing facility and ICF/IID room and board in addition to the per diem payment when a resident recipient elects hospice.

Physician Services

Florida Medicaid reimburses for the following separately, in addition to the per diem payment, in accordance with the applicable Florida Medicaid fee schedule(s) when rendered by a practitioner licensed within the scope of their practice:

• Consultations provided by a physician whose opinion or advice regarding the evaluation or management of a specific problem is requested by another physician or the hospice
• Hospital services for the evaluation and management of initial hospital admission, subsequent care, and discharge services
• Nurse practitioner services in accordance with 42 CFR 418.304(2)
• Office and home visits

For more information regarding covered services refer to AHCA Hospice Coverage Policy.

Billing: The following codes are included below 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 contract with Sunshine Health to determine all contracted/covered codes for each membership group.

Billing Codes and Modifiers

*To assist in claim adjudication, providers need to bill days 0-60 and 61+ on separate lines.

**SIA (0551/G0299, 0561/G0155) care hours are combined and cannot exceed four hours total per day. Hours provided concurrently count separately.

***Florida Medicaid reimburses for SIA (0551/G0299, 0561/G0155) care in addition to routine home care (0651) during the last seven days of an eligible recipient's life.

Please refer to the Medicaid Fee Schedule, and the Billing and Procedure Coding Guide for a list of approved modifier codes.

Note: To help minimize the risk of hospice claims being fully impacted by coding analytics denials, the recommended best billing practice is to bill Hospice Home Health/Home Care services (Q5001 to Q5010) on a separate claim line from the Level of Care, Routine Home Care, and Room and Board services (Rev Codes 0651, 0652, 0658, etc.), as these services are limited to one unit per day.

Providers must submit claims in a timely manner as indicated by the following table.

*In an initial claim, days are calculated from the date of service to the date received by Sunshine Health.

** In a reconsideration or claim dispute, days are calculated from the date of the explanation of payment/correspondence issued by Sunshine Health to the date the reconsideration is received by Sunshine Health.

*** For coordination of benefits, days are calculated from the date of explanation of payment from the primary payer to the date received by Sunshine Health.

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 Secure Provider Portal in response to an underpaid or denied claim.

Prior processing will be upheld for corrected claims or claim disputes received following the 90-day period unless there is a qualifying circumstance and appropriate documentation to support the qualifying circumstance. Qualifying circumstances may include:

• A catastrophic event that substantially interferes with normal business operation of the provider or a natural disaster that results in damage or destruction of the provider’s business office or records.
• Provider documentation showing that a member refused or was unable to provide member identification card and that the provider was unaware the member was eligible for services at the time they were rendered.

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:

• PaySpan
• Call: 1-877-331-7154
• Email: providersupport@payspanhealth.com

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.

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

• Provider Demographic Updates Tool
• Call: 1-844-877-8313
  
  

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

• Provider Enrollment Requests Form
  

Credentialing Tools

• Credentialing
• Delegated Credentialing
• Facility Credentialing
  

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.

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 and 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

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:

• Provider Support Guide: Find the Right Contact
  
• Provider Services: Call 1-844-477-8313
• Secure Provider Portal: Visit the Secure Provider Portal to check member eligibility, submit claims and more.
• Provider Engagement: Use the Find Your Account Manager tool to find the Provider Engagement Account Manager (PEAM) supporting your specialty and region.
• Claim Concerns: Resolve outstanding claims using the Claim Concerns form.
• Provider News: Bookmark Provider News to keep up with the latest updates.
• Provider Newsflash: Subscribe to our e-newsletter to get regular updates.
• Provider Resources: Visit Manuals, Forms and Resources to find provider manuals, important forms, scheduling standards and other resources.

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.

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.

• 988 Lifeline
• Call or Text: 988
• Chat with a Trained Counselor

Training

Sunshine Health offers a wealth of Provider 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. Sunshine Health (MMA)

Find A Provider (FAP) Tool

The Find a Provider 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.