Sunshine Health Therapy Program

• TNFL administers therapy services at outpatient free standing facilities for Sunshine Health’s MMA, SMI, and CW members ages 3 and above enrolled in Sunshine Health.
• Member ages 0-2 are managed by Sunshine Health.

• Long-Term Care (LTC)
• Medicare
• Children's Medical Services (CMS) Health Plan Members ages 0-2 years*
• Early Intervention Services (EIS)
• Prescribed Pediatric Extended Care (PPEC)
• Outpatient hospitals 

*Note: Members will be managed by TNFL on the date of their 3^rd birthday.

• If member has an active Plan of Care when they turn 3 years old, Sunshine Health will continue to manage PT/OT/ST services. Once the Plan of Care expires, a new authorization request should be submitted to TNFL.
  

Please submit your authorizatio request through Sunshine Health's Secure Provider Portal.

Participating TNFL therapy providers should continue to obtain authorizations via the TNFL Provider Web Portal. To reference full guidelines for authorization requests, please reference the Provider Resources page in the online TNFL Provider Manual (PDF).

Non-participating TNFL providers may submit authorization requests via fax at 1-855-410-0121.

Please submit your authorization request through eviCore's Secure Provider Portal. Authorizations are not required post October 3, 2022, if the member is 3 years old or younger.

Please submit your authorization request through Sunshine Health’s Secure Provider Portal.

Providers wishing to service these members can Join Our Network. Sunshine Health will reach out to you regarding participation after you provide the requested information.

Call TNFL at 1-888-550-8800 and select Option 2 to speak with an in-house Provider Relations Representative.

Your authorization should allow both in-person and telehealth services as needed.

• The prescription from the PCP, evaluation, and plan of care (POC) are required for an authorization review and are required to be uploaded with the request.
• The POC does not need to be signed in order to authorize. As long as it is there, we can process the authorization; however, the signed POC should be sent in when available OR prior to/with the renewal request.

A prescription from the child’s pediatrician is required.

Please be as specific as you can within the request and indicate number of visits for set duration of time.

No, Sunshine Health does not require authorization for children 0-3 years.

We measure units by number of visits.

• Be as specific as you can within the request and indicate the number of visits for a set duration of time.
• Clarify prior to authorization being reviewed/approved, if the request does not have units or visits originally requested. We are unable to review further without quantities listed.

Authorizations are issued to the group TIN with the understanding that treating providers may change.  An authorization is not specific to POS, as that often changes, as well.

• Dates cannot be backdated if the request is submitted after the DOS start date.
• Please allow sufficient time before rendering services to request an initial or re-authorization.
• If the request is received before the DOS start date, but reviewed after the start date, it can be backdated to match the request.

The telehealth place of service to utilize when billing services is 02.

• Please continue billing your claims to Sunshine Health the same way you always have.
• The only thing changing is the method of obtaining the authorization. The new authorizations will likely show OP; however, there is no need for a new authorization until the “A” authorization DOS has ended.

• Nothing has changed with our Sunshine Health MMA members.
• You will continue to work with TNFL/HN1 or Sunshine Health dependent on the age of the child, line of business, and/or location.
• The guidelines can be found on our Therapy web page.

Seven (7) days should be sufficient, but authorization requests can be submitted up to 30 days prior to the DOS.

All places of service follow the same procedure for authorization for CMS members.

This information may be helpful for increased visits or initial requests, but it is not required.

• We will begin processing requests on 10/3. Until then, Evicore should review any requests.
• We do not backdate requests unless the request was received prior to beginning DOS and not processed until after the start date.

This can depend on the provider group. Sometimes a group is listed as non-par, while the individual practitioners are listed as par. When requesting authorization, it’s best to supply Sunshine Health with both the NPI of the group and individual practitioner, when applicable.

• No. The Medicaid ID, name, and DOB should identify any member.
• Sunshine Health does not take authorizations by phone. Requests must be submitted either fax or the Secure Provider Portal, with the Secure Provider Portal being preferred.

Initial Evaluations do not require prior authorization; however, Re-Evaluations do require prior authorization.

Submit evaluations via fax or through the Secure Provider Portal as an attachment.

All places of service follow the same procedure for auth for CMS members.

• All places of service follow the same procedure for authorization for CMS members.
• If you are faxing in the request, there is a “therapy in PPEC” option on the MMA form. This will be added to the CMS form asap. Until then, it can be written on the form.

If the PCP has referred to a specialist and the specialist orders therapy, yes.

• Current authorizations are valid until the end of the DOS. Providers do not need to obtain a new authorization number until the authorization expires.
• When an authorization does expire after 10/3, a new authorization must be submitted to Sunshine Health for services to continue.