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Prescribed Pediatric Extended Care (PPEC) Provider Quick Reference Guide (QRG)

Contact Information, Provider Help and Resources

Prescribed Pediatric Extended Care (PPEC) centers allow Medicaid eligible children from birth through 20 years of age with medically complex conditions to receive continual medical care in a non-residential setting. While children may receive up to 12 hours of care per day, Sunshine Health only reimburses for medically necessary therapy services (physical, occupational, and speech therapies). To enroll as a Medicaid provider, a PPEC must be licensed pursuant to Chapter 400 Part VI, Florida Statutes, and be in compliance with Chapter 59A-13, Florida Administrative Code. A PPEC located in Alabama or Georgia that regularly provides services to Florida Medicaid recipients may enroll as an in-state Florida Medicaid provider. All enrollment requirements that apply to in-state providers apply to Georgia and Alabama providers as well, but those PPEC providers must have licenses and permits applicable to the state in which they are located. Providers should utilize this educational guide to supplement information outlined in our Provider Manual (PDF).

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 Florida KidCare Children’s Health Insurance Program (CHIP)

Note: PPEC daycare component codes T1025 (Full Day PPEC services 5-12 hours)/T1026 (Partial Day PPEC services four or less hours per day billed in units of one hour) for Title 21 Florida KidCare (CHIP) members are not covered by Sunshine Health. These daycare components should be billed directly to the state’s utilization management partner, Acentra Health. Sunshine Health does cover remaining PPEC services for Title 21 Florida KidCare (CHIP) members.

CMS Health Plan Resources

Visit Manuals, Forms and Resources to find provider manuals, important forms and other resources.

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 or CHIP 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 or CHIP 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.

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.

Fax

To fax a prior authorization request, select 331 Rehab (PPEC) using this fax form:

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 seven 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.

CMS Health Plan Payer ID:  68069

Covered Services

  • Nursing Services
  • Personal Care
  • Developmental Therapies
  • Caregiver Training
  • Respiratory Therapy Services

Note: Daycare components of PPEC services such as routine nursing, personal care, and extended attendance (T1025/T1026) are funded through Florida KidCare (Title 21) and should be billed directly to the state’s utilization management partner, Acentra Health,

For more about covered services, visit the AHCA Prescribed Pediatric Extended Care (PPEC) 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

Physical Therapy

15 minutes

97110

 GP

Therapeutic Exercises

1 Unit

Physical Therapy Eval

Per Encounter

97161-97163

 GP

PT Evaluation (Low to High complexity)

1 Unit

Occupational Therapy

15 minutes

97530

 GO

Therapeutic Activities

1 Unit

Occupational Therapy Eval

 

Per Encounter

97165-97167

 GO

OT Evaluation (Low to High Complexity)

1 Unit

Speech

Therapy

 

15 minutes

92507

 GN

Speech, Language, Voice Treatment

1 Unit

Speech Therapy Eval

 

Per Encouter

92521-92524

 GN

Speech-Language evaluation codes

1 Unit

*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 (PDF) and the Billing and Procedure Coding Guide for a list of approved modifier codes.

Note: All therapy services must be medically necessary and authorized as per Medicaid.

Important Links

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

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.

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 damage or destruction of the provider’s business office or records by a natural disaster
  • Provider documentation showing member refused or was unable to provide member identification card and provider was unaware the member was eligible for services at the time services 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:

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

Visit: 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.

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. 

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 telehealth vendors. 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 CMS Access and Availability Timeframe Standards.

Find A Provider (FAP) Tool

To find a specialist or facility for a member, visit 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.

Vendors 

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