Long Term Care (LTC) Skilled Nursing Facility (SNF) Quick Reference Guide (QRG)
Sunshine Health offers the comprehensive Long Term Care (LTC) plan for members ages 18 years and older who have complex healthcare needs and are also eligible for Medicaid. Our plan offers comprehensive physical and behavioral health services and programs, tools and support to help providers and caregivers improve the health and quality of life of our members. Our goal is to keep members living in their home or in the community when possible.
Skilled Nursing Facility (SNF) providers serve and temporarily house LTC members who require specialized care while undergoing rehabilitation and/or treatment after a period of hospitalization or illness. Providers should utilize this educational guide to supplement information outlined in our Provider Manual (PDF).
This Quick Reference Guide (QRG) covers the following product: Long Term Care (LTC)
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.
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.
Sunshine Health Portal: Secure Member/Caregiver Portal
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.
- Fax
- Download: Find the Inpatient Prior Authorization Fax Form (PDF) via the Pre-Auth Check Tool.
- LTC Fax: 1-844-416-8319
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
- Behavioral Health (BH) Fax: 1-855-407-5688
- LTC Fax: 1-844-416-8319
- Pharmacy Services Fax: 1-833-546-1507
- Note: Utilize these Treatment/Service Request Forms for fax submission online.
- 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)
- LTC: 1-866-796-0530, 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
Covered Services
- Skilled Nursing
- Rehabilitation Services
- Long Term Care
For more about covered services and nursing facility rates, visit the NAHCA Nursing Home Rates resource.
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
Service Type | Units of Measurements | Procedure Code | Modifier | Procedure Code Description | Units |
|---|---|---|---|---|---|
Nursing Facility Services | Per Day | 0101 |
| Long term care days | Units |
Nursing Facility Services | Per Day | 0185 |
| Hospital leave days | Units |
Nursing Facility Services | Per Day | 0182 |
| Home leave days (Therapeutic leave days) | Units |
**Please refer to the Medicaid Fee Schedule, and the Billing and Procedure Coding Guide for a list of approved modifier codes.
Important Links
- Nursing Home Providers Must Submit Prior Auth for LTC Residents Starting October 1, 2025
- Nursing Home Rates
- Medicaid Fee Schedule
- Billing and Coding: Evaluation and Management Services Provided in a Nursing Facility
- Nursing Facility (PDF)
- AHCA Provider Reimbursement Schedules and Billing Codes
- Provider Guide: AHCA Rules For Medicaid Enrollment, Billing
- Sunshine Health – Multiple Claim Submission Wizard LTC (PDF)
- Manuals, Forms and Resources
Providers must submit claims in a timely manner as indicated by the following table.
Initial Claim* | Reconsiderations or Claim Dispute** | Coordination of Benefits*** | |||
|---|---|---|---|---|---|
Participating | Non-Participating | Participating | Non-Participating | Participating | Non-Participating |
180 days | 365 days | 90 days | 180 days | 90 days | 90 days |
*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.
Claim Concerns
Sunshine Health strives to resolve claim issues promptly and accurately. Providers should 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 utilize our Claim Concerns form to resolve the issue. 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 Concerns Form
- Status Check: Wait 30 days, then to check on the status of your request call Provider Services at 1-844-477-8313
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.
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
Provider Enrollment Requests Form
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.
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: LTC
- 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: Finding 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.
- LTC: 1-866-796-0530, follow prompts for Nurse Advice Line, then option 1, option 3 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 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. See 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 the Access and Availability Timeframe Standards to find the guidelines that apply to your organization. See Sunshine Health (MMA)
Find A Provider (FAP) Tool
This tool can help members find a specialist or facility. Search by provider name, National Provider Identifier (NPI) and specialty type: Find a Provider Tool
Community Resources
Links members and caregivers in need with local programs and support with Sunshine Health Connects
Vendors
Visit our vendor resource page to find subcontractors and vendors and how to contact them.
FAQ: Long Term Care (LTC) Skilled Nursing Facility (SNF) Prior Authorization Frequently Asked Questions
Sunshine Health requires nursing home providers to submit prior authorization (PA) requests for custodial and skilled services when a Long Term Care (LTC) member resides in a Skilled Nursing Facility (SNF). This took effect on October 1, 2025. This frequently asked questions (FAQ) guide will help providers understand this process and learn how to submit claims and authorization requests. For more information about this process, visit Sunshine Health Provider News.
Why did the LTC prior authorization process for SNF facilities change in 2025?
Sunshine Health implemented this process for SNF facilities to align with authorization requirements for all LTC provider types; to ensure compliance with state requirements; to better track members and their locations; and for administrative purposes.
Does the new prior authorization policy apply to MMA and DSNP plans, or just LTC plans?
This process only applies to the LTC plan. The MMA prior authorization process remains in place and will continue to follow the 120-day requirement. The DSNP process will continue to follow the Wellcare (Medicare) process and remain in place.
Will the Secure Provider Portal have the authorization term date listed in preparation for renewal authorizations, or will providers be expected to keep a list of dates for each member?
We are working to add LTC SNF prior authorization requests to the Secure Provider Portal and will announce when it is ready. Until then, SNF providers should fax LTC SNF prior authorization requests to 1-844-416-8319. The authorization will be for 12 months. The start and end dates will be based on member eligibility and SNF placement.
Will bed hold authorizations require a separate prior authorization request, or will they be added onto the existing authorization?
LTC SNF prior authorization requests for members will count as one authorization and the bed hold will be placed on the member’s existing LTC SNF authorization as a second line item. The member LTC SNF authorization line will be pended and the second bed hold line added and utilized for the member. When the member returns to the SNF, the health plan will review the time remaining on the member’s existing prior authorization and the LTC SNF authorization portion will be updated for member/provider utilization. If the member’s LTC SNF prior authorization expires before they return to the facility, the health plan will review the member’s authorization renewal based on member eligibility and SNF placement criteria.
What is the timeframe for notifying the health plan about bed hold days?
Bed hold requests must be submitted five calendar days from the date Sunshine Health receives the member bed hold request.
What is the process if the facilities do not have 95% capacity and do not meet the criteria for bed hold days? Will these prior authorizations be denied?
Prior authorization requests will be reviewed. They must meet Medicaid guidelines for member eligibility and medical necessity. SNF authorization requests for SNF bed holds will be reviewed by the health plan based on facility census criteria and the guidelines mentioned above.
What is the timeframe to submit a prior authorization request?
Prior authorization requests must be submitted within five calendar days of the LTC member’s admittance to a SNF facility. The requests will be reviewed by the health plan and must meet Medicaid guidelines for member eligibility and medical necessity. Prior authorization must be requested within five calendar days of the first day the LTC member is enrolled in the SNF.
Authorization requests received after the 5-calendar day guideline will be reviewed by the plan. However, once medical necessity has been determined, the authorization request would begin on the date of the authorization request and will not retro back to the day the member was admitted to the facility. Authorizations must be requested within five calendar days of the first day of enrollment with the plan.
When will the guidelines for retroactive payments be available?
Claims are reviewed and adjudicated based on provider claim submissions and claim processing guidelines. The provider must ensure that the member’s approved LTC SNF authorization is on file. The member’s Department of Children and Families (DCF) Notice of Case Action (NOCA) for the member portion if applicable for room and board share of cost claims must also be correctly submitted to the plan.
Will providers need the member’s prior authorization number once Sunshine Health enters the first round of authorizations?
Sunshine Health will provide LTC SNF member prior authorizations by October 1, 2025. The facilities will receive the authorization letter via email or fax with the eligible member’s applicable information and authorization number. Authorizations will be approved based on the LTC member’s SNF eligibility criteria, and the auth will be valid for 12 months.
Is the plan only approving the LTC SNF authorization if the PASSR is provided?
The provider must submit a completed Preadmission Screening and Resident Review Process (PASRR) within seven days of the prior authorization request. If the PASRR is not included in the prior authorization request, the health plan will request it. If the PASRR is not received within seven days, the prior authorization request will be denied.
What is the fax number to send authorizations?
LTC Fax: 1-844-416-8319
What is the timeframe for notifying the health plan about bed hold days?
Bed hold requests are five calendar days from the date Sunshine Health receives the member bed hold request.
Will providers submit requests to renew authorizations, or will Sunshine Health auto-renew them?
LTC custodial authorizations will automatically renew depending on member eligibility and SNF placement.
Will Sunshine Health give prior authorization for LTC members with non-ICP Medicaid benefits plans such as the MWA (wavier) plan?
Providers are expected to ensure the member’s Medicaid eligibility. If after being admitted to a SNF facility, the member is not eligible for LTC ICP Medicaid in FLMMIS, the provider should work with DCF and the member’s authorized representative to ensure that the member’s eligibility for LTC Medicaid coverage is converted from MWA (Community) to ICP (Custodial). Once the health plan receives the LTC SNF prior auth request, it will review the member’s eligibility within FLMMIS. Providers should monitor the AHCA portal for ICP approval and Sunshine Health LTC ICP plan enrollment.