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Partners in Care: Together for Kids (PIC:TFK) Provider Quick Reference Guide (QRG)

ContactInformation, Provider Help and Resources

Partners in Care: Together for Kids (PIC:TFK) is a special program providing palliative care support services to Children’s Medical Services (CMS) Health Plan Title 19 and Title 21 members who have a life-limiting/threatening illness. PIC:TFK works with CMS Health Plan members and their families to provide extra support. They help meet physical, emotional, and spiritual needs. Services are provided by specially trained hospice providers who have experience with palliative care and children.

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

  • Children’s Medical Services (CMS) Health Plan Title 19
  • Children’s Medical Services (CMS) Health Plan Title 21

Enrollment in PIC:TFK is voluntary. To qualify, the member must be:

  • Enrolled in CMS Health Plan
  • Diagnosed with a serious condition
  • Live in an area where there is a PIC:TFK provider

PIC:TIK Providers (North to South)

  • Community Hospice & Palliative Care (Jacksonville)
    • Counties: Baker, Clay, Duval, Nassau, St. John’s
  • Halifax Health (Orlando)
    • Counties: Osceola, Orange
  • Treasure Coast Hospital (Fort Pierce)
    • Counties: Martin, St. Lucie
  • Suncoast Hospice (Tampa Bay)
    • Counties: Hillsborough, Pinellas
  • Tidewell Hospice (Sarasota)
    • Counties: Charlotte, DeSoto, Manatee, Sarasota
  • Hope Healthcare (Fort Myers)
    • Counties: Hendry, Glades, Lee
  • Trustbridge Hospice Care (South Florida)
    • Counties: Broward, Palm Beach

  • Must be a licensed Hospice Provider in the state of Florida with an active Medicaid ID
  • Must be contracted and credentialed with Sunshine Health as a provider

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.
  • The portal can be used by any registered provider to 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 all PIC:TFK services. When submitting authorization requests specifically for hospice services, please:

  • Include “Partners in Care:Together for Kids” by using place of service 390.
  • Submit a signed plan of care along with authorization request form.

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.

  • 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.

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.

To find resources like the PIC:TFK Referral form, Physician Certification form, Discharge or Transfer form and more, visit DOH Partners in Care: Together for Kids (PIC:TFK).

CMS Health Plan Payer ID:  68069

Covered Services

  • Chaplain services
  • Child-Life specialists
  • Counseling
  • Grief counseling
  • Nursing care
  • Pain and symptom control
  • Play, music, and art therapies
  • Respite care
  • Sibling support
  • Support for the entire family

Description of the Specialty: PIC:TFK services are provided by specially trained hospice providers. These providers have experience with palliative care and children. While a child is treated by a hospice provider, they are not hospice patients.

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

PIC: TFK Services

Unit = 45 minutes/ 3 units per day

G0176

UB*

Activity therapy (with a

registered or board-certified

therapist)

PIC: TFK Services

Not to exceed 12 units per month

S9123

UB*

Hospice nursing care

PIC: TFK Services

Unit = 1 hour

 

7 days per year total respite allowed

S9125

UB*

Respite care, in the home – home health agency (HHA)

PIC: TFK Services

Unit = 1 hour

S9122

UB*

Home health aide  or certified nurse

PIC: TFK Services

Unit = 30 minutes/ 4 units per day

 

Not to exceed 40 units per month

99510

UB*

Home visit for individual, family or MA (master’s degree level)

*Any portion of the hour that exceeds 15 minutes may be rounded up to the next hour after the first hour. Please refer to the Medicaid Fee Schedule and the Billing and Procedure Coding Guide for a list of approved modifier codes.

Electronic Claims Submissions

Electronic claims can be submitted via the Secure Provider Portal or the EDI clearing houses listed. Set up accounts with a clearing house via:

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.

Change Healthcare 

Paper Claims Submission

Medical Claims 

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

Billing Form

  • Services must be billed by utilizing the current standard CMS 1500 (HCFA) claim form.
  • All corrected claims should be free of handwritten or stamped verbiage and submitted on a CMS 1500 claim form.
    • Providers must include the original Sunshine Health claim number and bill frequency code per industry standards.
    • The bill frequency code should go in the left-hand side of Box 22.
  • Providers who bill electronically are responsible for filing claims within the same filing deadlines as providers filing paper claims.
  • Instructions for completing the CMS 1500 claim form can be found at: CMS Processing Manual: Chapter 26 (PDF).

Timely Claim Submission

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

Timely Claim Submission

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 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.

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.

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.

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.

Contact Information, Provider Help and Resources

CMS Health Plan

  • Provider Services 
    • Call: 1-844-477-8313
    • Hours: Monday through Friday from 8 a.m. to 8 p.m. Eastern
  • Pharmacy Services
    • Call: 1-800-460-8988, Option 2    
    • Hours: 24 hours a day, 7 days a week
  • Member Services
    • 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.

  • 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.

Access and Availability Timeframe Standards

Sunshine Health establishes and assesses provider compliance with appointment wait times for various types of visits. View the CMS 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, visit our 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.

Vendors 

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