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Holiday Member Services hours: Wednesday, November 23, 2022, 8 a.m.-6 p.m. Eastern. Closed Thursday and Friday, November 24-25, 2022.
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Holiday Member Services hours: Wednesday, November 23, 2022, 8 a.m.-6 p.m. Eastern. Closed Thursday and Friday, November 24-25, 2022.

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, Medicare, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan)
    • Effective date: October 1, 2021
    • 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)
    • Effective date: February 1, 2021
    • 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)
    • Effective date: June 1, 2021
    • 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)
    • Effective date: July 1, 2021
    • 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
    • Exclusions: DME, Non-Medicare Lines of Business, Regions 8-11 will be managed by the Health Plan
  • Central Florida Orthopedics Associates (Medicaid, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan)
    • Effective date: October 1, 2021
    • 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)
    • Effective date: October 1, 2021
    • 1-855-481-0505
    • Delegated function: Coverage of Services (DME, Home Health), Provider Services
    • Delegated function description: Utilization Management (authorizations)
    • Services: DME (Statewide), Home Health (MMA, CWSP, SMI, CMS)
    • 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 CMS
  • Coastal Care Services (Medicare)
    • Effective date: October 1, 2021
    • 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 will be managed by the Health Plan
  • Dental MCOs - Services not managed by Sunshine Health
  • Dermatology Network Solutions (Medicare)
    • Effective date: October 1, 2021
    • Delegated function: Coverage of Services (Dermatology), Provider Services
    • Delegated function description: Utilization Management (authorizations), Network Management, Provider Credentialing & 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, Children's Medical Services Health Plan Title 21)
    • Effective date: October 1, 2021
    • 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, Children's Medical Services Health Plan Title 21
    • Exclusions: Medicaid, Children's Medical Services Health Plan Title 19
  • Envolve People Care NurseWise (Medicaid, Medicare, Commercial/Ambetter, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan
    • Effective date: February 1, 2021
    • 1-844-234-0810
    • Delegated function: Coverage of Services, Enrollee Services
    • Delegated function description: Health Risk Assessments (authorizations), Enrollee Toll-Free Help Line
    • Services: Nurse Advice Line/BH Crisis Line
    • Exclusions: N/A
  • Envolve Pharmacy Solutions (Medicaid, Medicare, Commercial/Ambetter, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children's Medical Services Health Plan)
    • Effective date: October 1, 2021
    • 1-800-460-8988 (phone)
    • 1-866-399-0928 (PA requests)
    • Delegated function: Administration & Management Services, Coverage of Services, Enrollee Services, Provider Services
    • Delegated function description: Pharmacy Benefits Manager, Service Authorization, Utilization Management (authorizations), Mailing Fulfillment, Network Management, Provider Credentialing & Contracting, Toll-Free Provider Help Line, Claims & Provider Payment
    • Services: Pharmacy Benefit Management
    • Exclusions: N/A
  • Envolve Vision (Medicaid, Medicare, Commercial/Ambetter, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan)
    • Effective date:  October 1, 2021
    • 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)
    • Exclusions: N/A
  • Focus Health Management (Medicaid, Medicare, Child Welfare Specialty Plan, Long Term Care, Serious Mental Illness, Children’s Medical Services Health Plan)
    • Effective date: August 1, 2021
    • 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)
    • Effective date: October 1, 2021
    • 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
    • Exclusions: N/A
  • Health Network One (Medicaid, Child Welfare Specialty Plan, Serious Mental Illness)
    • Effective date: October 1, 2021 
    • 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
  • Hearing Care Solutions (Medicare)
    • Effective date: December 11, 2018
    • 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)
    • Effective date: October 1, 2021
    • 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)
    •  Effective date: October 1, 2021
    • 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
    • Exclusions: N/A
  • LabCorp (Medicaid, Commercial/Ambetter, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan)
    • Effective date: October 1, 2021
    • 1-800-845-6167
    • Delegated function: Provider Services
    • Delegated function description: Lab vendor
    • Services: Lab Services, Specialized Testing, STAT & Same Day Testing
    • Exclusions: N/A
  • LabCorp (Medicare)
    • Effective date: October 1, 2021
      • 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
      • Exclusions: N/A
  • Little Havana Activities & Nutrition Center (Long Term Care)
    • Effective date: October 1, 2021
    • 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
  • Medical Transportation Management (MTM) (Member transportation service for Children's Medical Services Health Plan
    • 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
  • 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: 1-877-659-8421
  • National Imaging Associates Inc. (NIA), an affiliate of Magellan Health Services, for radiology and cardiac imaging benefit management.
    • 1-877-807-2363
  • New Century Health (NCH), an oncology quality management company, to implement a new oncology pre-approval program, Sunshine Health Oncology Pathway Solutions.
  • Quest Diagnostics (Medicaid, Commercial/Ambetter, Child Welfare Specialty Plan, Serious Mental Illness, Children's Medical Services Health Plan)
    • Effective date: October 1, 2021
    • 1-866-697-8378
    • Delegated function: Provider Services
    • Delegated function description: Lab vendor
    • Services: Lab Services, Specialized Testing, STAT & Same Day Testing
    • Exclusions: N/A
  • Quest Diagnostics (Medicare)
    • Effective date: October 1, 2021
    • 1-866-697-8378
    • Delegated function: Provider Services
    • Delegated function description: Lab vendor.
    • Services: Lab Services, Specialized Testing, STAT & Same Day Testing
    • Exclusions: N/A
  • TurningPoint Healthcare Solutions, LLC for Musculoskeletal, Cardiac and ENT Surgical Procedures.