Q4 2024 Connected In Care

Evolent handles prior authorization requests for Sunshine Health members undergoing invasive cardiovascular procedures and services rendered in a physician’s office, outpatient hospital, ambulatory or inpatient setting.

The Evolent Cardiology Solution Program applies to Managed Medical Assistance (MMA), Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP), Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI) and Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV) members ages 21 years and older.

Sunshine Health manages cardiology services for MMA, CW, and SMI members ages 20 years and younger.

Evolent also oversees cardiovascular authorizations for Ambetter Health members ages 19 years and older. Ambetter Health directly manages cardiology services for members ages 18 and younger.

TurningPoint will continue to manage cardiology prior authorization for Children Medical Services (CMS) Health Plan members. But it no longer provides cardiology services for MMA, CWSP, SMI, HIV and Ambetter Health members.

Learn more about Evolent managing Sunshine Health’s Cardiology Solution Program in 2025.

Sunshine Health offers weekly Provider Town Halls to help providers learn about the latest health plan policies and guidelines and answer their questions. All the sessions are virtual, but we invite you to join us for select in-person sessions held at our Community Connections Centers across Florida. Providers can register and attend as many sessions as they wish.

Our town wall webinars address provider areas such as:

• Electronic Visit Verification (EVV)
• Home Health Provider
• Durable Medical Equipment (DME)
• Assisted Living Facility (ALF)
• Therapy, including Pediatrics

Visit Provider Training to register for upcoming Town Hall sessions.

There’s a new section of training materials dedicated to Applied Behavior Analysis (ABA) at Sunshine Health’s provider training web page. To find assessment, request and transition plan tips and other resources, visit the ABA section of Provider Training.

Sunshine Health has launched our new Provider Demographic Updates Form, which is designed to make it faster and easier for providers to update their practice information. This will help patients find out about your practice, help you better serve our members and help the health plan better serve our providers.

Providers who want to add or remove service locations, add or remove practitioners or submit W-9s can perform other tasks can do so by visiting Provider Demographic Updates.

Sunshine Health’s Quick Reference Guides are designed to give providers the information they need about their specialty areas in a convenient, organized and compact format. Now we’ve revamped our QRGs to make them even more accessible.

QRGs can help providers navigate these areas:

• Verifying member eligibility
• Obtaining authorizations
• Claims processing
• Updating provider information
• Contacting health plan departments

Visit Billing and Claims for our library of QRGs.

The Agency for Healthcare Administration (AHCA) has updated the rules that govern diabetic supplies provided to patients via Florida Medicaid.

Learn more about AHCA updates rules for Florida Medicaid’s diabetic supplies.

Visit Diabetic Supply Services for more information or call the Florida Medicaid Provider Helpline at 1-877-254-1055.

Sunshine Health is handling authorizations for Ear, Nose and Throat (ENT) services for Managed Medical Assistance (MMA), Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP) and Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI) members.

TurningPoint provides ENT services for Children’s Medical Services (CMS) Health Plan, but no longer oversees MMA, CWSP and SMI members.

Ambetter Health takes over ENT authorizations for those members on May 1, 2025. Until then, TurningPoint authorizations issued before then will be effective until the authorization end date.

Learn more about Sunshine Health administering ENT service authorizations.

Providers play a powerful role in identifying individuals who are at risk of suicide. Primary care is an important avenue to detect those at risk of suicide and to intervene. That’s why Sunshine Health is offering a free, virtual and accredited continuing education course entitled “Identifying and Supporting Individuals at Risk for Suicide.”

This 90-minute course will empower providers and their staff to identify and support at-risk individuals and help them receive timely and effective support. It is accredited by the Centene Institute for Advanced Health Education and offered in partnership with Sunshine Health.

Learn more about training providers to identify and support patients at risk of suicide.

Sunshine Health’s partnership with Health Network One has ended. Sunshine Health now administers Physical Therapy, Speech Therapy and Occupational Therapy (PT/OT/ST) services for members of all Medicaid products of all ages.

The health plan amended the agreements with providers contracted with Managed Medical Assistance (MMA), Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP) and Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI) members to allow them to treat members of all ages.

Visit Therapy to learn more about the many therapy benefits available to our members and our updated Therapy Quick Reference Guide (QRG).

Learn more about Sunshine Health ending its partnership with Health Network One.

Sunshine Health offers free, self-paced, virtual training sessions to help providers with the 8-hour training requirement for all Drug Enforcement Administration (DEA)-registered practitioners on the treatment and management of patients with opioid or other substance use disorders.

Register or learn more about Medication Assisted Treatment (MAT) training.

Sunshine Health reminds providers to adhere to the Centers for Medicare & Medicaid Services (CMS) guidelines for ICD-10 diagnosis codes. Before providers request authorization requests or submit claims, they should utilize billable diagnosis codes to prevent authorization returns and/or claim denials.

Learn more about not submitting non-billable diagnosis codes.

Our Healthy Behaviors Program, also known as the My Health Pays® Program, aims to inspire members to take actions that improve their health.

The program addresses members' health needs across a spectrum, from general wellness to managing chronic conditions. It is built on the principle of “meeting members where they are,” helping them take the first step toward healthier behaviors and supporting them in maintaining those behaviors for better health outcomes.

Learn what programs are available to CMS members.