Vendors
Sunshine Health has contracted with the following vendors for service:
- AcariaHealth (specialty pharmacy)
- 1-866-796-0530 Phone
- 1-866-351-7388 (Fax) PA Requests
- Access Behavioral Health (Medicaid, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan)
- 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, Region 1 only
- Exclusions: Regions 2-11 will be managed by the Health Plan
- Alivi (Long Term Care, Comprehensive LTC)
- Reservations: 1-888-863-0248 (TTY 711) between 8 a.m. and 5 p.m. Eastern, Monday through Friday
- Ride Assist (Where’s My Ride?): 1-877-659-8421
- 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, Medical Transportation for Comprehensive LTC Only
- Exclusions: Non-LTC Lines of Business, Emergency Transportation
- Biotel (Medicaid, Medicare, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-888-312-2328
- Delegated function: Coverage of Services (Disease Management)
- Delegated function description: Care Coordination/Case Management, Disease Management
- Services: Biometric Screening and monitoring, On-Demand Disease Management Program
- Exclusions: Ages 0-14
- CareCentrix (Medicare)
- 1-800-808-1902
- Delegated function: Coverage of Services (Home Health), Post-Acute Care
- Delegated function description: Utilization Management (authorizations), Claims Services, Network, Credentialing
- Services: Home Health, Regions 1-7
- Exclusions: DME, Non-Medicare Lines of Business, Regions 8-11
- Central Florida Orthopedics Associates (Medicaid, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-863-666-3436
- info@cfosa.com
- Delegated function: Provider Services
- Delegated function description: Claims & Provider Payment
- Services: Claims, Provider Payments, Region 7 only
- Exclusions: Commercial (Ambetter), Regions 1-6 will be managed by the Health Plan, Regions 8-11 will be managed by the Health Plan
- Coastal Care Services (Medicaid, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-855-481-0505
- Delegated function: Coverage of Services (DME, Home Health), Provider Services
- Delegated function description: Utilization Management (authorizations)
- Services: DME & Home Health (MMA, CWSP, SMI)
- Exclusions: Home Infusion Services & PDN will be managed by the Health Plan for MMA, CWSP, & SMI. Home Health, Home Infusion Services & PDN will be managed by the Health Plan for Children’s Medical Services 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: Home Health/DME Regions 8-11
- Exclusions: Regions 1-7
- CVS/Caremark
- 1-800-311-0539
- 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
- Dental MCOs - Services not managed by Sunshine Health
- Dermatology 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
- Exclusions: All counties except Miami-Dade, Broward, Palm Beach, Martin, St. Lucie will be Managed by the Health Plan
- Envolve Dental (Medicare, Commercial/Ambetter)
- 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 19, Children's Medical Services Health Plan Title 21
- Envolve Vision (Medicaid, Medicare, Commercial/Ambetter, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan)
- 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)
- Focus Health Management (Medicaid, Medicare, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children’s Medical Services Health Plan)
- Delegated function: Coverage of Services (Behavioral Health)
- Delegated function description: Utilization Management (authorizations)
- Services: Conducts utilization management for Behavioral Health authorizations the Health Plan submits
- Exclusions: Determination Letters are sent out under the Focus MD’s name. All correspondence is initiated by the Health Plan. Focus does not interact with members or providers.
- 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 (Medicaid, Child Welfare Specialty Plan, Serious Mental Illness)
- 1-800-595-9631
- Delegated function: Coverage of Services (Therapy), 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: OT, PT, ST, Free Standing Facilities Only, HN1 will manage all services for 3 years & above
- Exclusions: Ages 0-2 will be managed by the Health Plan. Outpatient Hospital, PPEC, EIS, Tertiary, Respiratory Therapy
- Health Network One - Dermatology (Medicare)
- 1-800-595-9631
- Delegated function: Coverage of Services (Dermatology), Provider Services
- Delegated function description: Utilization Management (authorizations), Service Authorization, Network Management, Provider Credentialing & Contracting, Claims & Provider Payment
- Services: Dermatology
- Exclusions: All counties except Lake, Orange, Osceola, Seminole will be Managed by the Health Plan.
- 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, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan)
- 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: Medicare
- HHAeXchange (Medicaid, Children's Medical Services Health Plan)
- 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, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan)
- 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, Only Regions 9-11
- Exclusions: Regions 1-8
- Liberty Dental (Children Medical Services Title 21)
- Effective Date: January 1, 2023
- 1-877-855-8039
- 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
- Exclusion: Medicaid, Ambetter, Medicare & Children's Medical Services Health Plan Title 19
- Medical Transportation Management (MTM) (Member transportation service for Children's Medical Services Health Plan
- 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)
- o Reservations
- o Member Nurse Advice Line (Medical advice 24/7)
- 1-866-796-0530 (Medicaid and Comprehensive Long-Term Care)
- 1-855-463-4100 (Child Welfare)
- ModivCare (Member transportation service for Medicaid, Child Welfare and Serious Mental Illness)
- Reservations: 1-877-659-8420 (TTY:1-866-288-3133) between 8 a.m. and 5 p.m. Monday through Friday.
- Ride Assist (Where’s my Ride): 1-877-659-8421 (24/7/365)
- Reservations
- National Imaging Associates Inc. (NIA) for radiology and cardiac imaging benefit management.
- New Century Health (NCH), an oncology quality management company, to implement a new oncology pre-approval program, Sunshine Health Oncology Pathway Solutions
- Pharmacy Services (Medicaid, Medicare, Commercial/Ambetter, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan)
- 1-800-460-8988 (phone)
- 1-866-399-0928 (PA requests)
- Delegated function: Coverage of Services, Enrollee Services,
- Delegated function description: Service Authorization, Utilization Management (authorization). Mailing Fulfillment.
- Services: Pharmacy Services
- Quest Diagnostics (Medicaid, Commercial/Ambetter, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan)
- 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
- TurningPoint Healthcare Solutions, LLC (Medicaid, Medicare, Commercial/Ambetter, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children Medical Services)
- 1-866-697-8378
- Delegated function: Coverage of Services
- Delegated function description: Utilization Management, Service Authorization, Toll-Free Provider Help Line, Provider Complaint System
- Services: Orthopedic, Surgical/Musculoskeletal Procedures + Cardiac Procedures