Q1 2026 Connected In Care

Sunshine Health’s Provider Town Hall training sessions each focus on a specialty area. Providers and their staff can attend as many virtual sessions as they wish. But you can also join our hybrid in-person/virtual sessions that will be held in our Sunshine Health Community Connections Centers across the state.

Register for as many virtual sessions as you wish. But space is limited for our in-person sessions,  so please register in advance and email your RSVP to eventconfirmations_flpr@sunshinehealth.com. 

To register, visit Training and scroll down to Provider Town Halls.

Sunshine Health offers providers virtual Clinical Documentation Improvement (CDI) webinars throughout the year to help you and your staff improve your practice’s coding and documentation to comply with regulatory requirements. These training sessions are focused on the 2026 Model ICD-10 and CMS ICD-10 Resources.

Check the schedule of virtual CDI webinars and register for the sessions that interest you and attend as many as you wish.

For other provider training options, visit Training and register for the sessions that interest you.

Sunshine Health’s Community Investment Report highlights our commitment to strengthening Florida communities through innovative programs, meaningful partnerships, and strategic investments that support better health outcomes. As a valued provider partner, you play a critical role in our mission to transform the health of our communities.

In 2025, we partnered with more than 700 community‑based organizations (CBOs) to support housing stability, food security, youth mental health, maternal health, and workforce development across the communities we serve. Through grants, sponsorships, and hands‑on engagement, our partnerships helped close gaps in care, expand access to resources, and support individuals and families where they live, work, and learn.

The Community Investment Report showcases the impact of these efforts and the collective progress made through collaboration with community leaders, nonprofit partners, and Sunshine Health employees. Together, we are building healthier and more resilient communities one partnership, one connection, and one person at a time.

To learn more about these initiatives and their impact, read the full 2025 Sunshine Health Community Investment Report (PDF).

Sunshine Health provides an annual reminder of the information available our website  that can help you deliver the best care for your patients. Patient satisfaction and positive health outcomes start with clear communication and the building of trust, and Sunshine Health appreciates your focus on keeping patient relationships strong. To learn more about how Sunshine Health helps providers offer the best healthcare to our members, visit Quality Care.

Sunshine Health offers an incentive to obstetricians (OBs) who meet C-section birth targets in their Agency for Healthcare Administration (AHCA) region. OB providers can earn an additional $500 per quarter if they meet the C-section birth target set in their ACHA region for a total of up to $2,000 for the year. The goal of this program is to safely reduce the number of C-section births taking place. Learn more about the C-section birth incentive.

At Sunshine Health, we're committed to making it easier for providers to work with us and ensuring timely, accurate claims processing. To support this, we are updating how prior authorization and claims are handled when Sunshine Health is the secondary payer. Learn more about the updated secondary payer policy.

Sunshine Health wants to support our rural providers by helping them improve their technology to proactively engage their patients. Our Rural Health Provider Technology Grant offers eligible rural providers grants of up to $10,000 to improve the technological systems they use to serve their patients. Learn more about the Rural Health Provider Technology Grant.

Sunshine Health gives members and providers the right to appeal decisions that affect their care and services. To help navigate this process, we created a Medicaid Member and Provider Appeal Processes Frequently Asked Questions Guide to explain the differences and similarities between the member and provider appeal processes.

Sunshine Health reminds hospital providers about the importance of properly utilizing the Inpatient Prior Authorization Fax Form (PDF) to submit prior authorization (PA) requests. This is not applicable to emergency room (ER) stays that become concurrent. Completing the form accurately helps prevent delays in the delivery of healthcare services to your patients, our members. Here’s more guidance on the information required for Medicaid elective inpatient authorization requests.

The Agency for Health Care Administration (AHCA) requires Behavior Analysis (BA) providers to have an active National Provider Identifier (NPI) to submit claims and enroll in Florida Medicaid. This requirement took effect on March 27, 2026. BA providers (Provider Type 39) now need an active NPI to submit claims via the Florida Medicaid Secure Portal. Learn more about this change and the NPI and BA resources available to providers.

The following drug manufacturers voluntarily withdrew from the Medicaid Drug Rebate Program (MDRP). The Centers for Medicare and Medicaid Services (CMS), in compliance with Social Security Law Sec. 1927 [42 U.S.C. 1396r–8] (a), requires drug manufacturers to participate in the program for their drugs to be considered covered under the Medicaid Program. This agreement is required for drugs to be considered for coverage under the Medicaid program. Because of this decision to withdraw, Medicaid Pharmacy Program no longer covers the drugs made by the manufacturers on this list as of October 1, 2025.

Ambetter Health reminds providers that it's time for the Quarter 1 2026 Appointment Wait Time Audit. Providers are required to adhere to the Ambetter Health Provider Standards for Appointment Scheduling for medical and behavioral health services both during and after office hours. This applies to in-person and telehealth visits. We want to work with your practice to ensure medical and behavioral health services are available to our members, your patients, on a timely basis. Learn how to ensure your practice complies with the Ambetter Health appointment standards.

As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Sunshine Health wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care. Learn more about the code changes.

As part of Sunshine Health, in partnership with Evolent Specialty Services to manage utilization management, certain prior authorization (PA) requirements were removed effective April 1, 2026. As part of our ongoing work to improve the PA process for providers and members, Sunshine Health is removing PA requirements for select Radiology & Diagnostic Cardiology & Cardiology codes. Here’s a list of codes that have been affected.

Evolent (formerly New Century Health) manages prior authorizations for Centene for Medical Oncology, Radiation Oncology, Pediatric and Dose Optimization, and Cardiology. As of

April 1, 2026, the procedure codes in the following link now require prior authorization through Evolent. This change applies to all Ambetter Health (Marketplace), Medicaid, and Medicare products offered by Centene. View the affected procedure codes.

We value our partnership with you and appreciate your ongoing commitment to providing quality care to our members. Effective March 1, 2026, Sunshine Health will administer prior authorizations for Ear, Nose and Throat (ENT) services for Children’s Medical Services (CMS) Health Plan members. These services were previously provided by TurningPoint. Learn more about this prior authorization change.

Effective March 1, 2026, Sunshine Health will administer prior authorizations for cardiology services for Children’s Medical Services (CMS) Health Plan members. These services were previously provided by TurningPoint. Beginning March 1, 2026, please submit prior authorization requests to Sunshine Health via the Secure Provider Portal. Learn more about the cardiology prior authorization changes.

Sunshine Health covers biomarker testing in alignment with the Agency for Health Care Administration (AHCA) policy. AHCA updated the Medicaid Laboratory Services Coverage Policy to include coverage of biomarker testing effective June 1, 2025. Biomarker tests require prior authorization and are reviewed for medical necessity.

Sunshine Health is committed to ensuring children get the genetic testing they need when they need it. Our policies align with The American Academy of Pediatrics recommendations and guidelines for whole exome sequencing (WES) and whole genome sequencing (WGS) testing for pediatric patients who have a diagnosis of global developmental delay/intellectual disability, but not inclusive of children with a diagnosis of Autism Spectrum Disorder alone. When medically necessary criteria are met, testing must be completed by in-network laboratories for non-emergent cases. Sunshine Health reminds providers that for pediatric patients in an ICU setting, rapid genetic testing is approved regardless of whether the lab is in-network or out-of-network.