Q4 2025 Connected In Care
Sunshine Health Now Manages Expressive Therapy Network
Sunshine Health directly oversees the Expressive Therapy (ET) network as of December 31, 2025. Expressive therapies, including music, art, equine and pet therapy, will remain a covered service for members. This is a part of our commitment to providing access to high-quality, clinically appropriate care for our members. Medical Transportation Management (MTM) no longer oversees ET services for our members. To learn more about this transition, or to learn how to join the Sunshine Health network, visit:
Behavior Analysis News
Sunshine Health adheres to the AHCA Medicaid Behavioral Analysis Services Policy Handbook (PDF), including all outlined requirements. We have provided additional clarification to help reduce confusion, specifically regarding the Comprehensive Diagnostic Evaluation (CDE) documentation requirements. Remember, CDEs must follow national evidence-based practice standards. Learn more about CDE documentation requirements
As previously announced, Sunshine Health has implemented a temporary pause on adding new practitioners to existing Behavioral Analysis (BA) provider groups. We understand unique circumstances may arise, so we created a new Exception Request Form for providers seeking consideration during the pause.
Sunshine Health has clarified billing and authorization requirements for Comprehensive Diagnostic Evaluations (CDEs) involving codes 96112, 96113, 96160 and 96161.
Providers should no longer include the HN modifier when submitting authorization requests for CPT codes 97155 and 97156. To learn more about this change, visit No HN modifier for CPT Codes 97155 and 97156
Providing Quality Care
Sunshine Health provides an annual reminder of the information available our website that can help you deliver the best care for your patients. Patient satisfaction and positive health outcomes start with clear communication and the building of trust, and Sunshine Health appreciates your focus on keeping patient relationships strong. To learn more about how Sunshine Health helps providers offer the best healthcare to our members, visit Quality Care.
Prior Authorization News
Sunshine Health has shared some important updates to our prior authorization (PA) requirements. This work is aligned with broader industry efforts, driven by commitments to regulatory agencies and America’s Health Insurance Plans (AHIP), to modernize and streamline prior authorization. Providers should familiarize themselves with these changes.
Effective March 1, 2026, Sunshine Health will administer prior authorizations for cardiology services for Children’s Medical Services (CMS) Health Plan members. These services were previously provided by TurningPoint. Beginning March 1, 2026, please submit prior authorization requests to Sunshine Health via the Secure Provider Portal.
Effective March 1, 2026, Sunshine Health will administer prior authorizations for Ear, Nose and Throat (ENT) services for Children’s Medical Services (CMS) Health Plan members. These services were previously provided by TurningPoint.
As of January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) has implemented 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.
Other News
Sunshine Health reminds providers that the Agency for Healthcare Administration (AHCA) has set important enrollment and billing requirements that they must follow as Medicaid providers. We created an online guide to help providers understand those rules and how to resolve any issues.
Sunshine Health has clarified contracting and billing requirements for Early Intervention Services (EIS) providers. Providers who deliver EIS do not need to be contracted with Sunshine Health to provide these services, as long as claims are billed using the appropriate Taxpayer Identification Number (TIN), CPT code(s), and modifier(s).
Do you know how long it should take for your practice to schedule a routine visit for a patient? What if it’s an emergency? Sunshine Health, Ambetter Health and Wellcare remind providers that they must adhere to each health plan’s standards for scheduling appointments with their patients, our members.
Standards for Appointment Scheduling
Interoperability is a secure way for healthcare systems and software applications to share electronic medical records (EMR) that could support better patient outcomes. This can be completed through EMR systems, such as Epic Systems, Healow, Athenahealth, and Oracle Health. At Sunshine Health, our interoperability solution is designed to support our provider partners by improving efficiency, reducing costs, and enhancing patient care.
Sunshine Health is sharing guidance from the Agency for Health Care Administration (AHCA) regarding coverage and reimbursement for rapid whole genome sequencing (rWGS) services.
Effective January 1, 2026, prior authorization (PA) is now required for therapeutic behavioral onsite services. This applies to all providers except those who render services to members ages 0-3 years old. Learn which codes and modifiers will be impacted.
Sunshine Health reminds providers that they should always keep their W-9 tax form up to date. Remember, an outdated W-9 could result in the withholding or misdirection of payment from the health plan. Learn more about why and how providers can keep their W-9 updated.
Sunshine Health has updated our contact details for pharmacy appeals. Make sure you’re using the right fax number, the right phone number and the right mailing address.
As of October 1, 2025, Sunshine Health implemented a requirement for Skilled Nursing Facilities (SNFs) to obtain prior authorization for LTC members residing in the facility. Learn more about how to comply with this requirement.
The Agency for Health Care Administration (AHCA) has updated the Practitioner Laboratory Fee Schedule to include recently added Biomarker Codes. To find the updated information, visit AHCA Provider Reimbursement Schedules and Billing Codes and scroll down to the Practitioner Laboratory Fee Schedule. Learn more about AHCA Biomarker Codes
Sunshine Health providers should ensure that their laboratory services are completed through in‑network partners. Using in‑network labs helps prevent unnecessary delays and avoids issues that can impact both your practice and our members.