Q3 2025 Connected In Care
Providers can use the new Claim Concerns form to submit unresolved claims issues directly to the right team.
The Claim Concerns form is designed to simplify and improve the resolution of outstanding claim issues. It offers a convenient entry point that automatically routes submissions to the team best equipped to review and resolve claim issues. The form will capture all the necessary information upfront to streamline the process, reduce delays and ensure your claim issues are handled efficiently and quickly resolved.
This enhancement is part of Sunshine Health’s continuing efforts to improve the provider experience by moving to more reliable web submission tools.
Sunshine Health will deny all electronic visit verification (EVV) claims that are not electronically verified or are missing the appropriate exception reason code. This is an important change Sunshine Health is making to fully comply with the 21st Century Cures Act.
To prevent reimbursement delays, providers are encouraged to reduce and eliminate EVV exceptions, including visit times that are manually adjusted.
Starting August 1, 2025, Sunshine Health began requiring prior authorization for all Targeted Case Management (TCM) and Psychosocial Rehabilitation (PSR) services for members ages 4 years old and above. This change does not apply to members under 4 years old.
Sunshine Health put together a Q&A to answer providers’ questions about TCM and PSR services.
Starting January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) will implement these new prior authorization (PA) response time requirements for all providers:
- Standard prior authorization requests will be completed within seven calendar days, with a possible extension up to 14 calendar days under certain circumstances.
- Expedited/Urgent prior authorization requests will be completed within the lesser of 72 hours or the current BD turnaround time.
All necessary clinical information should be submitted at the time of the authorization request due to shorter response times for supporting clinical information requests.
Ambetter Health has implemented a Site of Care (SOC) Optimization Program to support improved care delivery and cost-effectiveness for Ambetter Health members.
The program launched on October 1, 2025. Under this program, providers with members currently receiving infusions in outpatient hospital settings will be contacted to select an alternative home infusion or ambulatory infusion suite (AIS) option. Participating providers will receive outreach via fax or a phone call.
This outreach will request preferred site-of-care selections for individual members.
Wellcare implemented an additional review to ensure correct coding guidelines are followed for Electrodes for Transcutaneous Electrical Nerve Stimulation (TENS) to ensure appropriate billing.
The reviews started on November 1, 2025. This program is part of Wellcare’s commitment to continuously evaluating and improving overall payment integrity solutions as required by state and federal governing entities.
It is critical that providers use the correct taxonomy code on all Health Plan claims. For Medicaid products, the provider’s taxonomy code must align with the AHCA Provider Master List (PML).
The health plan will not update the taxonomy code unless the provider’s NPI number matches the PML.
Ambetter Health wants to help Home Health (HH) and Durable Medical Equipment (DME) providers quickly submit outpatient Prior Authorization (PA) requests for our members.
That’s why we created online resources to help providers navigate these processes:
Download: Ambetter Health HH/DME Prior Authorization QRG (PDF)
Effective October 1, 2025, Sunshine Health required nursing home providers to submit prior authorization requests for custodial and skilled services when a Sunshine Health Long Term Care (LTC) member resides in your facility.
This is critical to ensure compliance with state requirements, and ultimately, that our members receive all needed services when they need it, regardless of setting.
As of October 15, 2025, prior authorization is required for Ambetter Health providers billing HCPCS code H0019 (BHVAL HLTH; LNG-TERM RES PER DIEM).
When checking member eligibility, in the Ambetter Health section of the provider portal please note that if you see "CMS" listed in the Product Name field, this does not indicate that the member is part of the Children’s Medical Services (CMS) line of business.
Instead, "CMS" in this context refers to the ACA/Marketplace line of business offered by Ambetter Health. We understand this label may be confusing, and we are working to improve clarity in the system. In the meantime, please treat these members as Ambetter Health members.
If you have any questions or need further clarification, please reach out to your Provider Engagement Account Manager (PEAM).
Did you know that Sunshine Health and Ambetter Health members are eligible for one preventive visit per calendar year, not every 365 days? This means you can schedule and bill for a member’s annual wellness visit any time within the same calendar year. This helps ensure members receive timely preventive care without unnecessary delays.
Sunshine Health reminds Behavioral Analysis (BA) providers that Medicaid claims are subject to National Correct Coding Initiative (NCCI) rules, which prohibit billing multiple services that are considered overlapping or duplicative on the same day, unless an appropriate modifier is used.
Ambetter Health has contracted Optum to review and audit claim reimbursements for potential overpayments. Ambetter Health implemented this new process on August 1, 2025.
Ambetter Health contracted with Optum to review and audit claim reimbursements for potential overpayments. Optum will perform audits on claim payments to ensure overpayments are not a result of a billing error or a member having coverage with another payor.
Ambetter Health covers procedure codes 85003 (Comprehensive Metabolic Panel), 85025 & 85027 (Complete Blood Count), and 84443 (Thyroid Stimulating Hormone) individually and discontinued their coverage under bundled code HCPCS 80050 as of November 1, 2025.
The Centers for Medicare & Medicaid Services previously removed 80050 from the Medicare Clinical Lab Fee schedule, citing an overuse of the bundled code when not all services were being performed. Ambetter Health adopted this policy and will only cover the codes when they are submitted individually.
Learn more about the discontinuance of HCPCS Bundle Code 80050