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Vendors

Sunshine Health has contracted with the following vendors for service:

  • Access Behavioral Health (Medicaid (MMA), Sunshine Health Pathway to Shine Specialty Plan (CW), Sunshine Health Mindful Pathways Specialty Plan (SMI), Children's Medical Services Health Plan (CMS), and Sunshine Health Power to Thrive Specialty Plan (HIV))
    • 1-866-477-6725
    • abhinfo@bhcpns.org
    • Delegated function: Coverage of Services (Behavioral Health), Provider Services
    • Delegated function description: Utilization Management (authorizations), Network Management, Provider Credentialing & Contracting, Claims & Provider Payment
    • Services: Behavioral Health Services, in-lieu services, inpatient and outpatient services in  Escambia, Okaloosa, Santa Rosa and Walton only
    • Exclusions: All other counties will be managed by the Health Plan
  • Alivi (Medicaid, CW, Comprehensive LTC, Long Term Care, SMI, HIV)
    • Reservations between 8 a.m. and 5 p.m. Eastern, Monday through Friday; and Ride Assist (Where’s My Ride?) 24/7, 365 days a year
    • Delegated function: Coverage of Services (Transportation), Enrollee Services, Quality, Provider Services
    • Delegated function description: Enrollee Material, Enrollee Toll-Free Help Line, Satisfaction & Experience Surveys (Enrollee and/or Provider), Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
    • Services: Non-Emergent Transportation
    • Exclusions:  CMS, Emergency Transportation; Air Ambulance
  • Alivi (Medicare)
    • Reservations: 1-855-519-6684 between 8 a.m. and 5 p.m. Eastern, Monday through Friday
    • Ride Assist (Where’s My Ride?): 1-855-519-6684 (24/7, 365 days a year)
    • Delegated function: Coverage of Services (Transportation), Enrollee Services, Quality, Provider Services
    • Delegated function description: Enrollee Material, Enrollee Toll-Free Help Line, Satisfaction & Experience Surveys (Enrollee &/or Provider), Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
    • Services: Non-Emergent Transportation
    • Exclusions:  Emergency Transportation, Ambulance
  • CareCentrix (Medicare)
    • 1-800-808-1902
    • Delegated function: Coverage of Services (Home Health)
    • Delegated function description: Utilization Management (authorizations), Claims Services, Network, Credentialing
    • Services: Home Health in Region A to E only
      • Region A: Escambia, Okaloosa, Santa Rosa and Walton, Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, Washington
      • Region B: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union, Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia
      • Region C: Pasco, Pinellas
      • Region D: Hardee, Highlands, Hillsborough, Manatee, Polk
      • Region E: Brevard, Orange, Osceola, Seminole
    • Exclusions: 
      • Durable Medical Equipment (DME), Non-Medicare Lines of Business
      • Home Health in Regions F to I
        • Region F: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota
        • Region G: Indian River, Martin, Okeechobee, Palm Beach, St. Lucie
        • Region H: Broward
        • Region I: Miami-Dade, Monroe
  • CareCentrix (Medicare and Ambetter Health)
    • 1-800-808-1902
    • Delegated function: Coverage of Services (Post-Acute Care}
    • Delegated function description: Utilization Management (authorizations),
    • Services: Post Acute Care
    • Exclusions: Medicaid Lines of Business
  • Centene Dental Services (Commercial/Ambetter Health)
    • 1-855-735-4395
    • Delegated function: Coverage of Services (Dental), Provider Services
    • Delegated function description: Utilization Management (authorizations), Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Claims & Provider Payment
    • Services: Dental Services
    • Exclusions: Medicaid, Children's Medical Services Health Plan Title XIX and Title XXI
  • Centene Vision Services (Medicaid, Commercial/Ambetter Health, CW, SMI, CMS, HIV)
    • 1-800-531-2818
    • Delegated function: Coverage of Services (Vision), Provider Services
    • Delegated function description: Utilization Management (authorizations), Service Authorization, Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
    • Services: Vision Services (Optometry, Ophthalmology)
  • Central Florida Orthopedics Associates (Medicaid, Comprehensive LTC, SMI, CMS, HIV, Medicare)
    • 1-863-666-3436
    • info@cfosa.com
    • Delegated function: Provider Services
    • Delegated function description: Claims & Provider Payment
    • Services: Claims, Provider Payments, Counties: Orange, Seminole, Osceola
    • Exclusions: Long Term Care, Commercial (Ambetter Health), All counties except Orange, Seminole, Osceola
  • Coastal Care Services (Medicaid, CW, SMI, CMS, HIV)
    • 1-855-481-0505
    • Delegated function: Coverage of Services (DME, Home Health), Provider Services
    • Delegated function description: Utilization Management (authorizations), Toll-Free Provider Help Line
    • Services: DME & Home Health (MMA, CW, SMI, CMS)
    • Exclusions: 
      • Home Infusion Services & PDN: managed by the Health Plan for Medicaid CW, & SMI.
      • Home Health for CMS: Managed by the Health Plan
  • Coastal Care Services (Medicare)
    • 1-855-481-0505
    • Delegated function: Coverage of Services (DME, Home Health), Provider Services
    • Delegated function description: Utilization Management (authorizations), Network Management, Provider Credentialing & Contracting, Claims & Provider Payment
    • Services: DME: Statewide; Home Health: Regions F to I
      • Region F: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota
      • Region G: Indian River, Martin, Okeechobee, Palm Beach and St. Lucie
      • Region H: Broward
      • Region I: Miami-Dade, Monroe
    • Exclusions: Home Health Regions A to E
      • Region A: Escambia, Okaloosa, Santa Rosa, Walton, Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, Washington
      • Region B: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union, Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia
      • Region C: Pasco, Pinellas
      • Region E: Hardee, Highlands, Hillsborough, Manatee, Polk
  • Dental MCOs – (Medicaid dental benefits are not administered by Sunshine Health)
  • DentaQuest (Medicare)
    • 1-833-206-6288
    • Delegated function: Coverages of Services, Enrollee Services, Provider Services, Quality
    • Delegated function description: Utilization Management, Network Management, Provider Credentialing and Recredentialing, Claims Processing, Member Call Center, Provider Call Center, Quality Improvement
    • Services: Dental Services
    • Exclusions: Non-Medicare Lines of Business
  • Dermatology Network Solutions [parent company Provider Network Solutions] (Medicare)
    • 1-844-222-3535
    • Delegated function: Coverage of Services (Dermatology), Provider Services
    • Delegated function description: Utilization Management (authorizations), Network Management, Provider Contracting, Claims & Provider Payment
    • Services: Dermatology (Miami-Dade, Broward, Palm Beach, Martin and St. Lucie counties)
    • Exclusions: All counties except Miami-Dade, Broward, Palm Beach, Martin, St. Lucie will be Managed by the Health Plan; non-Medicare lines of Business
  • Evolent
    • Cardiology
      • Aged 21 or older (Medicaid, CW, SMI, HIV, Medicare, Ambetter Health)
      • 1-888-999-7713
      • Delegated function: Coverage of Services
      • Delegated function description: Utilization Management
        • Exclusions:
          • Emergent services, non-elective inpatient services
          • Aged 20 or younger Medicaid, CW, SMI, HIV and Medicare lines of business
          • Aged 18 or younger Ambetter Health
          • Long Term Care and Children's Medical Services (CMS) Health Plan lines of business
    • High-Tech Radiology, Cardiac Imaging and Musculoskeletal
      • Medicaid, SMI, HIV,  CMS
      • CW
      • Commercial (Ambetter Health)
      • Medicare
      • Web Portal
      • Delegated function: Coverage of Services
      • Delegated function description: Utilization Management, Service Authorization, Coverage of Services, Toll-Free Provider Help Line, Provider Complaint System
      • Exclusions: Long Term Care line of business
    • Oncology
      • Medicaid, Medicare, Commercial (Ambetter Health), CW, SMI, HIV, CMS
      • 1-888-999-7713
      • Delegated function: Coverage of Services
      • Delegated function description: Utilization Management, Service Authorization, Coverage of Services, Toll-Free Provider Help Line, Provider Complaint System
      • Exclusions: Long Term Care line of business
    • PT, OT, ST TherapyExternal Link
      • Commercial (Ambetter Health)
      • 1-800-424-4909
      • Delegated function: Coverage of Services
      • Delegated function description: Utilization Management, Service Authorization, Coverage of Services, Toll-Free Provider Help Line, Provider Complaint System
      • Exclusions: Non-Ambetter Health lines of business
  • Express Scripts (Medicaid, Commercial/Ambetter Health, CW, SMI, CMS, Wellcare, HIV)
    • 1-800-841-3044
    • Delegated function: Administration and Management Services, Enrollee Services, Provider Services
    • Delegated function description: Pharmacy Benefit Management, Mailing Fulfillment, Network Management, Provider Credentialing & Contracting, Claims & Provider Payment, Toll-Free Provider Help Line
    • Services: Pharmacy Benefit Management
  • Florida Care Management Services Agency (FCMSA) (Long Term Care)
    • 1-877-462-1200
    • Delegated function: Coverage of Services, Enrollee Services
    • Delegated function description: Care Coordination/Case Management, Utilization Management, Service Authorization, Enrollee Toll-Free Help Line
    • Services: Care Coordination/Case Management, Utilization Management
    • Services: Care Coordination/Case Management, Utilization Management for a subset of members in Palm Beach, Broward and Miami-Dade only all other counties (will be managed by the Health Plan)
    • Exclusions: All other counties
  • GT-Independence (Long Term Care)
    • 1-877-659-4500
    • Delegated function: Coverage of Services, Enrollee Services
    • Delegated function description: Participant Direction Option (PDO), Enrollee Material, Enrollee Toll-Free Help Line, Mailing Fulfillment
    • Services: PDO
  • Health Network One (Medicare)
    • 1-800-595-9631
    • Delegated function: Coverage of Services (Dermatology), Provider Services
    • Delegated function description: Utilization Management (authorizations), Network Management, Provider Credentialing & Contracting, and Claims & Provider Payment
    • Services: Dermatology (Lake, Orange, Osceola and Seminole counties)
    • Exclusions: All counties except Lake, Orange, Osceola, Seminole will be managed by the Health Plan; Non-Medicare lines of Business
  • Hearing Care Solutions (Medicare)
    • 1-866-344-7756
    • Delegated function: Coverage of Services (Hearing), Provider Services
    • Delegated function description: Enrollee Toll-Free Help Line, Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
    • Services: Audiology
    • Exclusions: Non-Medicare Lines of Business
  • HearUSA (Medicaid, Commercial/Ambetter Health, Comprehensive LTC, CW, SMI, HIV, CMS)
    • 1-855-242-4935
    • Delegated function: Enrollee Services, Provider Services
    • Delegated function description: Enrollee Toll-Free Help Line, Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
    • Services: Audiology
    • Exclusions: Long Term Care and Medicare
  • HHAeXchange (Medicaid, CMS)
    • 1-844-477-8313
    • Delegated function: Coverage of Services, Administration & Management Services
    • Delegated function description: Participant Direction Option (PDO), EVV Vendor, Electronic Visit Verification
    • Services: EVV, Billing Services, Portal
  • LabCorp (Medicaid, Commercial/Ambetter Health, CW, SMI, CMS)
    • 1-800-845-6167
    • Delegated function: Provider Services
    • Delegated function description: Lab vendor
    • Services: Lab Services, Specialized Testing, STAT & Same Day Testing
  • LabCorp (Medicare)
    • 1-800-845-6167
    • Delegated function: Provider Services
    • Delegated function description: Exclusive only for Wellcare Medicare
    • Services: Lab Services, Specialized Testing, STAT & Same Day Testing
  • Little Havana Activities & Nutrition Center (Long Term Care)
    • 1-305-858-0887
    • Delegated function: Provider Services, Enrollee Services
    • Delegated function description: Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment, Mail Fulfillment
    • Services: LTC Provider Services, in Palm Beach, Broward and Miami-Dade only
    • Exclusions: All other counties
  • Liberty Dental Plan (Children Medical Services Health Plan Title XXI)
    • 1-888-352-7924
    • Delegated function: Coverage of Services (Dental), Coverage of Services, Provider Services
    • Delegated function description: Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment, Enrollee Material, Enrollee Toll-Free Help Line, Utilization Management, Service Authorization
    • Exclusions: Medicaid, Ambetter Health, Medicare and Children's Medical Services Health Plan Title XIX
  • Medical Transportation Management (MTM) (Children's Medical Services Health Plan (CMS))
    • Routine Reservations: 1-844-399-9469 (TTY 711) between 8 a.m. and 7 p.m. Eastern, Monday through Friday, and 8 a.m. to 5 p.m. Eastern Saturday
    • Ride Assist (Where’s my Ride): 1-888-597-1185 (24/7, 365 days a year)
    • Reservations
    • Delegated function: Coverage of Services (Transportation), Enrollee Services, Quality, Provider Services
    • Delegated function description: Enrollee Material, Enrollee Toll-Free Help Line, Satisfaction & Experience Surveys (Enrollee &/or Provider), Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
    • Services: Non-Emergent Transportation
    • Exclusions: Non-Children’s Medical Services Health Plan Lines of Business; Emergency Transportation
  • Medical Transportation Management (MTM) (Medicaid, Comprehensive LTC, SMI, CW, HIV, CMS)
    • 1-866-848-9428 between Monday-Friday from 8 a.m. to 4:30 p.m. Eastern
    • Delegated function: Coverage of Services, Enrollee Services, Quality, Provider Services
    • Delegated function description: Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Provider Complaint System, Claims & Provider Payment
    • Services: HCBS Therapy (art, equine, music, pet)
      • Ages 21 & older for Medicaid, Comprehensive LTC, SMI, HIV; Or
      • EPSDT under age 21
    • Exclusions:
      • Under age 21 that does not fall under EPDST guidelines,
      • Long Term Care, Medicare, Commercial (Ambetter Health)
      • Authorizations, which are issued by the Health Plan
  • Premier Eye Care (Medicare)
    • 1-855-749-1911
    • Delegated function: Coverage of Services, Provider Services
    • Delegated function description: Utilization Management, Network Management, Provider Credentialing, Toll-Free Member Calls, Toll-Free Provider Calls, Provider Complaints
    • Services: Vision Services
    • Exclusions: Medicaid, Commercial/Ambetter Health, CW, Long Term Care, SMI, CMS
  • Quest Diagnostics (Medicaid, Commercial/Ambetter Health, CW, SMI, CMS)
    • 1-866-697-8378
    • Delegated function: Provider Services
    • Delegated function description: Lab vendor
    • Services: Lab Services, Specialized Testing, STAT & Same Day Testing
  • Quest Diagnostics (Medicare)
    • 1-866-697-8378
    • Delegated function: Provider Services
    • Delegated function description: Lab vendor.
    • Services: Lab Services, Specialized Testing, STAT & Same Day Testing
  • Surgery One (Medicaid, SMI, HIV, CMS, Medicare)
    • 1-352-275-5478
    • Delegated function: Provider Services
    • Delegated function description: Claims & Provider Payment
    • Services: Claims, Provider Payments, Counties: Orange, Seminole, and Osceola
    • Exclusions: Long Term Care, Commercial (Ambetter Health), and all counties except Orange, Seminole, Osceola
  • TurningPoint (CMS)
    • 1-855-415-7483
    • Web Portal
    • Delegated function: Coverage of Services
    • Delegated function description: Utilization Management, Service Authorization, Toll-Free Provider Help Line, Provider Complaint System
    • Services: Cardiac and ENT services for CMS Health Plan members
    • Exclusions: Non-CMS Health Plan lines of business