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Stay Connected on the Go! Download our Health Insurance Portal mobile app to search for care, view benefits and access your Member ID card. LEARN MORE AND DOWNLOAD THE APP
Stay Connected on the Go! Download our Health Insurance Portal mobile app to search for care, view benefits and access your Member ID card. LEARN MORE AND DOWNLOAD THE APP

Q2 2026 Connected In Care

 

When providers need help from Sunshine Health, sometimes they're not sure who to contact or what information they need to share. That's why Sunshine Health created a provider support tool to help connect providers with the right teams to offer support.

It's called the Provider Support Guide: Find the Right Contact tool. This tool is designed to reduce delays and expedite a resolution. The Provider Support Guide can help you and your practice with these issues:

  • Claims
  • Reconsiderations and Disputes
  • Provider Appeals
  • Contracting
  • Delegated Credentialing
  • Demographic Updates
  • Enrollment
  • Provider Engagement

Learn more about how the Provider Support Guide: Find the Right Contact tool can help you.

Sunshine Health wants to ensure that providers understand the definition of Expedited/Urgent Authorization requests.

Expedited/Urgent Service Authorization assignments are defined as requests that, if considered in a standard timeframe, could jeopardize the health or life of a member.

Submitting non-urgent requests as urgent can cause delays in processing as it floods our inventory with reviews that may not need urgent priority. It also requires outreach to verify urgency when the request does not meet the definition. Knowing when to submit expedited/urgent requests and being proactive in your requests can help reduce delays in authorizations for all the care your patients need.

Learn more from the Sunshine Health Expedited/Urgent authorization requests tip sheet.

Sunshine Health reminds providers that they must maintain a complete, current and up-to-date CAQH profile to prevent any issues that could affect their business relationship with the health plan. A provider’s CAQH (Council for Affordable Quality Healthcare) profile is a critical component of the credentialing and recredentialing process.

Outdated or incomplete CAQH information could delay or stall application reviews or cause other credentialing issues that could result in a lapse or interruption of your participation in the Sunshine Health provider network. For more information, select the following link:

Learn more about CAQH best practices.

Sunshine Health will begin requiring Behavior Analysis (BA) providers to include a PCP Acknowledgement and Care Coordination Form (PDF) with all new BA authorization requests. This requirement applies only to new BA authorization requests submitted on or after August 1, 2026. Authorizations submitted on or after August 1, 2026, will not be approved without this form. The goal is to ensure Primary Care Providers (PCPs) are aware when these services have been requested or are being provided to their members.

Learn more about the PCP Acknowledgement form now required for all new BA authorization requests.

Sunshine Health has partnered with Certify to send important credentialing and recredentialing emails to providers. Please watch out for these emails. Do not ignore them, delete them or treat them like spam. These are important, time-sensitive emails that providers must respond to as soon as possible. When you see an email in your inbox from Certify, it means you are due for credentialing or recredentialing.

Learn more about the importance of Certify’s credentialing emails.

The Agency for Health Care Administration (AHCA)'s temporary waiver of service limits for certain community behavioral health (BH) outpatient services has expired. As a result, Sunshine Health has resumed applying applicable Medicaid service limits for adults ages 21 years and older. BH service limits were reinstated starting Wednesday, July 1, 2026.

The waiver allowed certain BH outpatient service limits to remain waived while it was in effect. Now that the waiver has expired, Sunshine Health has reinstituted the service limits that were in place prior to the waiver, consistent with AHCA guidance and Medicaid coverage requirements.

Learn more about the resumption of BH outpatient service limits.

Sunshine Health is committed to helping our providers and members comply with a new Florida law that impacts student athletes and the healthcare they receive. The Second Chance Act requires all Florida high school athletes in the upcoming 2026-2027 school year to undergo an electrocardiogram (EKG) to help identify underlying heart conditions before they are allowed to compete in sports activities.

Learn more about the new law, correct billing codes and best practices.



Sunshine Health reminds providers that they must quickly notify the health plan when a practitioner separates from a practice, group or facility. This will help the health plan maintain an efficient and productive business relationship with your organization. Quickly notifying Sunshine Health about terminations will help prevent claim and credentialing issues, support compliance and accreditation standards, and make sure our directories contain the most up-to-date information.

Learn more about submitting provider termination requests.

Sunshine Health introduced newly redesigned, standardized member ID cards on April 17, 2026. Existing members were not reissued ID cards as part of this update. Only new members who enrolled in Sunshine Health or requested a replacement ID card on or after April 17, 2026, received the new card design. Both current and newly redesigned Sunshine Health ID cards are valid for member identification and eligibility verification.

Learn more about Sunshine Health’s updated ID cards.

Sunshine Health recognizes that Medication Assisted Treatment (MAT) is essential to improving outcomes for members with substance use disorders (SUD) and supporting providers in delivering high-quality care. That is why Sunshine Health offers providers an incentive program and training resources to help them help their patients.

Learn more about MAT training and the MAT incentive.

Ambetter Health reminds providers that if they are not a part of the Ambetter Health Solutions (ICHRA: Individual Coverage Health Reimbursement Arrangement) network, then they should not render services to Solutions members. Doing so will result in those claims being denied, or the provider receiving reduced reimbursement. Ambetter Health Solutions is an off-exchange marketplace network and is not interchangeable with the Ambetter Health Core, Premier, or Value networks.

Learn more about verifying Ambetter Health Solutions eligibility.

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.

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

Ambetter Health made some important updates to our prior authorization (PA) process as we continue to improve this important element for providers and members. Ambetter Health’s goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.

Learn more about the Ambetter Health PA updates.

Sunshine Health has enhanced its authorization matching logic to better align claims processing with the frequency approved on an authorization. As part of this enhancement, when an authorization is approved with a defined frequency, such as weekly, the system will match and apply authorized units based on that approved frequency rather than viewing the total units as fully available across the entire authorization span.

Learn more about authorization frequency-based approvals.

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.

Learn more about biomarker testing coverage and billing guidance.

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.

Learn more about genetic testing and lab options for children.