Thanks for being our partner in care!
On this website, SunshineHealth.com, you’ll find:
- Provider manuals, forms, directories
- Training materials
- Prior Authorization Tool
- Electronic transaction guide
- Child health checkup/EPSDT information
- PaySpan Health for EFTs/ERAs
- Provider News
- Clinical guidelines
- And more!
On our Secure Provider Portal, which you can access via the orange Login tab, you will find:
- PCP verification
- Member eligibility/verification
- PCP cost reports
- Claims submission/inquiry/adjustment
- Request Prior Authorization (PA)
Contact Provider Services, 8 a.m. to 8 p.m. Monday-Friday, at 1-844-477-8313 with questions or assistance with the following services:
- Questions about claim/credentialing/network status
- Request for adding physicians to an existing group
- Request a free copy of our Provider Manual
Electronic Data Interchange (EDI)
EDI support for HIPAA transactions is provided by Sunshine Health’s corporate office, Centene Corporation. For support, please contact our EDI Department at 1-800-225-2573, ext. 25525, or visit our website at
SunshineHealth.com. The website contains our electronic Billing Manual which offers detailed information regarding claims billing instructions, requirements for the CMS 1500/837 Professional, and the UB04/837 facility claim forms. Sunshine Health’s Payer ID is 68069.
Reconsiderations and Disputes
All requests for claims reconsideration or adjustment must be received within 90 calendar days from the date of notification of payment or denial (please refer to the provider manual for information regarding qualifying circumstances). Submit claim reconsiderations or adjustments through our secure web portal or mail to:
PO Box 3070
Farmington, MO 63640-3823
Timely Filing Guidelines
Initial Filing: 180 calendar days of the date of service Coordination of Benefits (Sunshine Health as Secondary); 180 calendar days of the date of service or 90 calendar days of the primary payer’s determination (whichever is later). Corrected/Reconsideration/Dispute : 90 calendar days from the payment/denial notification.
The Sunshine Health Medical Management team provides oversight of utilization management, case management and care coordination. Authorization must be obtained prior to the delivery of certain elective and scheduled services and can be submitted through the web portal or via fax.
- Inpatient Prior Authorization Form (PDF)
- Outpatient Prior Authorization Form - Medicaid (PDF)
- Outpatient Prior Authorization Form - Children's Medical Services (PDF)
Open the specific inpatient or outpatient PDF file and fill in the fields. Save the file as a new document, print the form and fax it to 1-866-796-0526. Please use a new online form for each request.
Medical Management/Case Management
- 1-866-796-0530 Monday–Friday, 8 a.m. to 7 p.m. EST/EDT
- 1-866-796-0526 (PA Fax)
- 1-877-689-1056 (Case Management Fax)
- 1-866-694-3649 (Behavioral Health PA Fax)
- Inpatient non-emergent admissions (elective)
- Physician office requests for plan approval
- Inpatient emergent or urgent admissions
- Hospital notifies Health Plan within 2 days of admission
- Newborn deliveries – Notification to Health Plan next business day
- Observation admission – Notification within the first 48 hours
- Out-Of-Network – Notification following stabilization of emergency care
See the Pre-Auth Check page for more information.
Members may call Sunshine Health to select and/or change their PCP assignment at any time. Members may also request language assistance or help with other issues.
- Medicaid/Long Term Care: 1-866-796-0530
- Child Welfare Specialty Plan: 1-855-463-4100
- Ambetter: 1-877-687-1169
- Allwell: 1-877-935-8022 (TTY: 711)
- Hours of Operation: Monday–Friday,8 a.m. to 8 p.m. ET
- 1-800-955-8770 (TDD/TTY)