Q3 2026 Connected In Care
Sunshine Health will transition to the Zelis financial platform to handle claims and non-claims payments starting in December and through early 2027. Providers should start moving onto the Zelis platform now to ensure uninterrupted access to electronic payments and remittance information.
The new payment system will be available in phases for all payments related to Sunshine Health (Medicaid), Ambetter Health (Marketplace), and Wellcare (Medicare) health plans.
Sunshine Health offers providers a wide array of interpreter services to help you communicate with your patients, our members.
Interpretation services are a covered benefit for all members of Sunshine Health (Medicaid), Ambetter Health (Marketplace), and Wellcare (Medicare). Providers will not be billed.
Learn more about what providers need to know about how our interpreter and translation services work and how to request them.
Sunshine Health in collaboration with Evolent is implementing updates to how musculoskeletal services are reviewed and administered to enhance the member and provider experience. Advances in surgical care have enabled many procedures that once required inpatient stays to be safely performed in outpatient settings.
Beginning November 3, 2026, Evolent will guide ordering providers during intake of an authorization request for Medicaid members to select a preferred site of care. Learn more about Evolent Musculoskeletal Updates.
Sunshine Health reminds providers that the Screening, Brief Intervention, and Referral to Treatment (SBIRT) incentive rewards them for helping deliver the best possible healthcare to our pregnant members. Providers who complete an SBIRT assessment within each pregnant member's first trimester are eligible for an additional $50 reimbursement per member.
SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for individuals with substance use disorders and those at risk of developing such disorders.
Private Duty Nursing (PDN) and Family Home Health Aide (FHHA) Services Policy for Medically Fragile Children
Sunshine Health wants to make Private Duty Nursing (PDN) and Family Home Health Aides (FHHA) providers aware of published policy changes made by the Agency for Health Care Administration (AHCA).
Private Duty Nursing (PDN) and Personal Care Services (PCS) Authorization Guidance Now In Effect
Sunshine Health supports the accurate and timely processing of PDN and PCS authorization requests. To help this process, providers should note Sunshine Health’s updated guidance regarding date spans and submission practices. Learn more about PDN, PCS Guidance.
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 about Expedited/Urgent authorization requests.
Sunshine Health has expanded its 100-day medication supply list to further support medication adherence for members managing chronic conditions including asthma, behavioral health conditions, diabetes, hypertension, and sickle cell disease.
The updated list now includes fluticasone propionate HFA controller inhalers to help improve asthma medication access and adherence.
Learn more about the Updated 100-Day medication supply list.
Sunshine Health is implementing a process for cases involving continuation of benefits during the Medicaid appeal and fair hearing process. Under the Medicaid Fair Hearing provisions of the AHCA SMMC Contract, if a member receives continued services during the appeal process and the final hearing decision upholds Sunshine Health’s action, Sunshine Health may seek recovery of costs for services furnished during the requested continuation of benefits period. Learn more about the Continuation of Benefits Fair Hearing Process.
Sunshine Health reminds providers that when a member transfers from one provider/practice/organization to another, they must adhere to specific requirements. This will help ensure a smooth transition for your patients, our members. Learn more about how BA provider changes require new authorization.
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 Medicaid PA Updates.
Ambetter Health wants to let providers know about a new tool that will help you support your patients’ medication use so you provide the best healthcare possible. RxEffect is a free medication adherence workflow platform developed by RxAnte that helps health plans, care managers, and providers improve patient outcomes. RxEffect uses predictive analytics to identify at-risk patients and prioritizes them for targeted clinical outreach. Learn how RxEffect can help patients.
New Electronic Visit Verification (EVV) Policy: Visits Must Not Exceed 24 Hours Per Day
Sunshine Health is informing providers about an important Electronic Visit Verification (EVV) enhancement feature that is now in effect: The health plan has implemented a new billing review edit to ensure that a billed visit doesn’t go over 24 hours for any member on a single calendar day.
Any visits over 24 hours a day will be held in billing review in the EVV system (HHAeXchange). EVV data should be reviewed prior to billing.
EVV Billed Units Must Match Billed Hours
Sunshine Health is letting providers who rely on Electronic Visit Verification (EVV) know that Florida third-party providers' billed units and hours must match the payer’s unit calculations for claims submitted through HHAeXchange. Total billed hours are calculated based on when the visit starts and when the visit ends. To learn more, visit EVV units, hours must match.
Managing authorization follow-ups just got easier with request for additional information (RFAI). You can securely receive and respond to requests from Sunshine Health, right within Availity Essentials. Key Benefits include no calls or faxes for authorizations, requests move faster, activity can be tracked in one place, and requests can be managed and monitored from a single dashboard. To learn more, visit Availity streamlines authorizations.