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Medical Foster Care (MFC) Quick Reference Guide

Contact Information, Provider Help and Resources

Sunshine Health provides personalized healthcare for children with complex needs in Florida’s child welfare system to care for their physical and behavioral health needs. The Medical Foster Care (MFC) program provides foster children with medical conditions opportunities to receive care within a family setting. Sunshine Health understands that improving the well-being of children is a community efforts. That’s why we builds a care coordination team around every child to best support their individual needs. Our integrated physical and behavioral health approach brings together healthcare providers, community-based care agencies, and foster, adoptive, permanent guardianship and biological parents to create a care plan to match each child’s needs.

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

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

Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP) serves children and youths up to the age of 21 who are enrolled in Medicaid and have an open case with Department of Children and Families (DCF) for extended foster care or a voluntary placement agreement to live and receive medical care and support in a home-like environment.

Children’s Medical Services (CMS) Health Plan recruits MFC parents and provides training for them to care for the medically necessary needs of each child.

Sunshine Health Payer ID: 68069

Covered Services

Specialized medical support team of healthcare providers, including a pediatrician, nurse and social worker who will coordinate care with specialists, hospitals, equipment providers, therapists, health facilities, schools and foster care staff.

For more information about covered services, refer to the AHCA Medical Foster Care (MFC) resource.

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.

Billing Codes and Modifiers

Service Type

Units of Measurements

Procedure code

Modifier

Procedure Code Description

Service Maximum Fee

Medical Foster Care Services (MFC)

Daily

S5145

HA

Level I Medical Foster

Care Service

$48.47

Medical Foster Care Services (MFC)

Daily

S5145

TF

Level II Medical Foster

Care Service

$60.59

Medical Foster Care Services (MFC)

Daily

S5145

TG

Level III Medical Foster

Care Service

$84.81

Claims Links

Timely Claim Submission

Providers must submit claims in a timely manner as indicated in 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

Prior authorization is not required for Medical Foster Care (MFC) services rendered in the home. If you believe your child needs additional services, please use the Pre-Auth Check Tool to determine which services require prior authorization. Secure Member/Caregiver Portal

Sunshine Health

Use Sunshine Health’s Secure Portal to check your child’s eligibility, verify benefits, submit a referral to Case Management, submit claims, submit claim reconsiderations, etc.

Availity Essentials

The same functions described above can also be completed using the Availity portal.

Provider Demographic Updates

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

Provider Enrollment Requests

To add a new practitioner or facility, find the required credentialing documents or to update your Affiliated Providers (LOAP)/Practitioner Roster form via the Practitioner Enrollment Requests Form.

Provider Claims Concerns or Challenges

If you have attempted an appeal or dispute via our normal channels and feel your concern(s) need additional review, please email all relevant details and supporting documentation to our Provider Services Intake team at Sunshine_Provider_Relations@SunshineHealth.com

Note: Claim reconsiderations can be filed via the Secure Provider Portal. This functionality is not yet available in Availity Essentials but is set to go live at a later date.

Explanation of Payments (EOPs)

Payspan

Access explanation of payment statements (EOPs), change bank account information register for electronic funds transfers. If you are currently receiving paper checks and would like to register for EFT, please view a copy of a current paper check. It should contain a Payee ID, which is the plan number that will be needed when registering.

Contact Payspan using 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.

Parent Credentialing & Enrollment

Parent Intent to Terminate

  • Parents should notify DOH in writing with 60-day advance notice of their intent to terminate their affiliation with the health plan.  
  • Parents should also inform the health plan by completing the termination section of the Provider Demographic Updates Tool.

Referrals to Case Management

Submit referrals via the Secure Provider Portal. Look under the Referrals tab of your child's member record. A successful submission will result in a confirmation message.

To reach Case Management (CM):

Adoption Advocates

Locally based and have knowledge about providers and resources in the community, can provide support for families before a crisis happens, and can connect parents to adoption support groups in their community. To contact our adoption advocates for help, please email PromotingAdoptionSuccess@SunshineHealth.com.

Clinical Training

We offer free, live clinical based trainings to help foster parents. Register for the sessions that interest you.

Contact Information, Provider Help and Resources

  • Provider Services: All products   
    • Call: 1-844-477-8313        
    • 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: CMS      
    • Call: 1-866-799-5321      
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern
  • 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

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: 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, dial or text 988, or chat with a trained counselor. The 988 Lifeline services are confidential, free of charge and available 24/7, 365 days a year. 

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.

Visit 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.

Find A Provider (FAP) Tool

To find a specialist or facility for a member, use the Find a Provider Tool. Search by provider name, NPI and specialty type.

Community Resources

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

Stay Up To Date 

Get the latest news and information by visiting For Providers  and Provider News.

Vendors 

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