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Sunshine Health Overview of Early Intervention Services (EIS) and EIS Targeted Case Management (TCM) Billing and Reimbursement

For all newly enrolled members, Sunshine Health allows for a continuity of care (COC) period for EIS and EIS TCM services as we do for other services that the member was receiving prior to enrolling in Sunshine Health. The COC periods are:

  • 60 days for MMA members
  • 90 days for Child Welfare members

This means that a provider can bill Sunshine Health for the EIS and EIS TCM services that a new member was receiving, prior to enrolling in Sunshine Health, without having a contract in place. Sunshine Health will pay the Medicaid FFS rate for these services, unless the provider was paid more. We will pay that higher amount for the first 30 days.

  • Sunshine Health system has been set up to pay all EIS and EIS TCM claims after the COC period

Early Intervention Services

Attached are the Early Intervention codes and modifiers. Please be sure to include the applicable modifier on your claim or the claim may be denied.

  • These claims are considered medical claims and submitted to the medical payor ID and claims addresses under "Submission of Electronic and Paper Claims."

Targeted Case Management for children ages 0 to 3 who are receiving Early Intervention Services

Attached are the Early Intervention Targeted Case Management codes and modifiers. Please be sure to include the applicable modifier on your claim or the claim may be denied.

  • These claims are considered behavioral health claims and submitted to the behavioral health payor ID and claims addresses under "Submission of Electronic and Paper Claims."
  • Electronic claims can be submitted through Sunshine Health secured provider portal or several EDI clearing houses.
  • Payor IDs that are to be used when submitting an EDI claim are:
    • Medical claims: 68069 (for EIS services – see section 2. above)
    • Behavioral health claims: 68068 (for EIS TCM services – see section 2. above)
  • Paper claims can be submitted to
Addresses for paper claims
Medical Claims (including EIS) Behavioral health claims (including TCM)

Sunshine Health 
P.O. Box 3070
Farmington, MO 63640-3823
Attn: Claims Department

Sunshine Health Plan
P.O. Box 6900
Farmington, MO 63640-3818
Attn: Claims Department

Providers can submit clean claims through a clearinghouse, paper billing or the Sunshine Health Secure Provider Portal (as noted above). Clean claims will require:

  • Correct code with modifier.
  • National Provider Identifier
  • Correct Taxonomy Code

A claim is defined as (1) a bill for services, (2) a line item of service, or (3) all services for one beneficiary within a bill. A clean claim means one that can be processed without obtaining additional information from the provider of the service or from a third party as outlined in 42CFR 447.45(b).

If an EIS or TCM provider has not executed a contract by the time a region is implemented, Sunshine Health will pay EIS or TCM claims from non-participating providers until the contract is executed.

Sunshine Health follows AHCA guidelines. Clean claims will be adjudicated within 15 days of receipt of an electronic claim or 20 days from receipt of a paper claim.

  • Ensure you are submitting a clean claim! This is information that must be on the claim:
    • Correct code with modifier.
    • National Provider Identifier
    • Correct Taxonomy Code
  • There are some common errors that result in denied claims. Consider these errors when submitting claims:
    • Submitting without a modifier (see Billing Guidelines" for the appropriate modifiers)
    • Submitting to the incorrect payor ID or claims address:
      • EIS codes to the medical payor ID or claims address
      • Targeted Case Management to the behavioral health payor ID or claims address
      • See "Submission of Electronic and Paper Claims" for the correct payor ID or claims address
    • Submitting the same claim or service twice (duplicate claim)
    • Submitting without including the Rendering Provider NPI Number

Training material for billing EIS and EIS TCM services (PDF) can be found on SunshineHealth.com. Under “For Providers,” select “Provider Training.” Scroll down the page to “Billing Guidelines” under “Other Training Resources.” 

Providers can call our Provider Services help line at 1-844-477-8313.

  • Claim related issues must be submitted with 90 days of the determination. These will be resolved within 60 days.
    • First time claim adjustment request are not part of the provider dispute process
    • Disputes can be submitted by calling 1-844-477-8313 or by mailing the provider claim dispute request form to
      Sunshine Health
      P.O. Box 3070
      Farmington, MO 63640-3823
Florida Medicaid Early Intervention Services Fee Schedule

Service

Procedure Code and Modifier

Evaluation and screenings

Per Early Intervention Services Fee Schedule

Assistive technology services and devices

Per the Durable Medical Equipment and Medical Supply Services Provider Fee Schedule for All Medicaid Recipients.

Procedure codes must include the TL modifier.

Audiology services

Per the Hearing Services Fee Schedule. Procedure codes must include the TL modifier.

Nursing services

Per the Home Health Visit Services Fee Schedule. Procedure codes must include the TL modifier.

Medical services (e.g., physician services)

Per the Practitioner Fee Schedule. Procedure codes must include the TL modifier.

Nutrition ser­­­vices

Must use Sessions as provided in the Early Intervention Services Fee Schedule

Occupational therapy services

Per the Occupational Therapy Services Fee Schedule. Procedure codes must include the TL modifier.

Physical therapy services

Per the Physical Therapy Services Fee Schedule. Procedure codes must include the TL modifier.

Psychological services

Per the Community Behavioral Health Services Fee Schedule. Procedure codes must include the TL modifier.

Sessions

Per Early Intervention Services Fee Schedule

Speech-language pathology

Per the Speech-Language Pathology Services Fee Schedule. Procedure codes must include the TL modifier.

Vision services

Per the Visual Services Fee Schedule. Procedure codes must include the TL modifier.

Updated 03-30-2020