Q2 2025 Connected In Care
Behavioral Analysis (BA) News
Sunshine Health reminds providers about important changes now in effect for all Targeted Case Management (TCM) and Psychosocial Rehabilitation (PSR) services:
- Sunshine Health now requires prior authorization for all TCM (T1017) and PSR (H2017) services for members ages 4 years old and above.
Learn more about the TCM and PSR changes
- Sunshine Health no longer covers PSR (code H2017) services delivered via telehealth.
Behavioral Analysis (BA) contracted providers undergoing the credentialing process that meet all regulatory and professional standards should continue delivering all medically necessary services that were authorized, regardless of how their network status currently appears in the plan system.
Sunshine Health will continue to process claims for these products in accordance with applicable guidelines and policies.
Providers are required to include specific documents when submitting a clinical authorization request. Sunshine Health adheres to the AHCA Medicaid Behavioral Analysis Services Policy Handbook (PDF) and all of its requirements. Select the following link to consult a list of those important documents:
Learn more about required BA provider documents
BA Resources
- BA Provider Quick Reference Guide (QRG): Sunshine Health’s one-stop guide with information about authorizations, billing, claims and other important topics.
- Frequently Asked Questions: This is regularly updated to answer providers’ latest questions.
After-Hours Cares News
Sunshine Health offers providers a $20 incentive for every member who receives healthcare services after hours. Our goal is to improve members’ access to healthcare, and an effective way to do that is for providers to offer services to their patients outside of their regular office hours.
What is considered after hours?
- Healthcare services rendered from 5 p.m. to 8 a.m. Local Time
- All weekends
- All holidays
- After-hours telehealth services are included
Sunshine Health wants to ensure appointments for medical and behavioral health services are available to all our members on a timely basis. The appointment availability standards are now available for all products:
Ambetter Health wants to help you provide the best care possible to your patients, our members. But we know there are times when you and your practice won’t be available to help them. Fortunately, your patients have options for obtaining care after office hours or during weekends and holidays — options that don’t involve going to the Emergency Room. Select the link below to find all the medical options available to your patients 24-7, 365 days a year:
Other News
Sunshine Health has made it easier for providers to submit demographic updates. We encourage providers to keep their demographic information up-to-date by selecting and bookmarking Provider Demographic Updates Tool
Add Facilities to Existing Contracts
Sunshine Health recently updated its step-by-step instructions and forms to help providers add a new facility to their existing Sunshine Health contract. Visit How to Add Facilities to Existing Contracts
Project ECHO® (Extension for Community Healthcare Outcomes) is a self-paced lifelong learning and guided practice model where a team of experts conduct virtual clinics with community providers to educate them on maternal health issues using real-life cases. This allows primary care doctors, nurses and other clinicians to learn how to provide specialty care to patients in their own communities. The next Project ECHO session will focus on Perinatal Substance Use, Medication-Assisted Treatment (MAT) and Screening, Brief Intervention, and Referral to Treatment (SBIRT). For more information, visit Sunshine Health Maternal Project ECHO.
Register Now
- Date: Thursday, October 23, 2025
- Time: 1 to 2 p.m. Eastern
- Registration: Perinatal Substance Use, MAT and SBIRT
Bring the Ambetter Health experience to your event with our branded van. Our field representative can be on-site to your practice or event to hand out Ambetter Health promotional items and discuss the benefits of our plans. Fill out the Ambetter Health Van Request Form to schedule a visit and enhance your event with valuable health information and giveaways.
Wellcare has released the latest Prior Authorization (PA) changes for Medicare providers that took effect on July 1, 2025.
Wellcare is committed to delivering cost effective quality care to our Medicare members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice.
Sunshine Health offers webinars on clinical topics to support our Long Term Care (LTC) providers delivering quality care to our members. The trainings are free, offered regularly throughout the year and cover topics such as:
- Abuse, Neglect & Exploitation of Vulnerable Adults
- Basics of Dementia
- Behavior Management
- Fall Prevention
- Older Adults and Mental Health
- Trauma-Informed Care When Working With Older Adults
- Substance Use Disorders: Overview for Health Care Providers
Register now: LTC Provider Webinar Series
Questions: bh_training@centene.com
Children’s Medical Services (CMS) Health Plan Wrap Up
Medication adherence is crucial to the health of our youngest members. That’s why CMS Health Plan alerts providers when their patients may not be refilling or adhering to their prescriptions.
The health plan reviews pharmacy claims data to determine whether children diagnosed with conditions such as asthma, diabetes, epilepsy, sickle cell disease or a behavioral health condition may not be refilling or adhering to their prescriptions. This can result in increased hospitalizations for some members.
Adherence can be defined as a member filling their prescriptions for a diagnosis at least 80% of the time over a 6-month period. Please look for communications from the health plan regarding your patients.