ALF Supports and Resources

Every Long Term Care member is assigned a Care Coordinator. The representative will visit your facility to meet with you and the member, working collaboratively to eliminate barriers to care. You can reach your Care Coordinator or a member of our team by calling 1-866-796-0530.

Need one-on-one help? We have dedicated Provider Engagement Administrators located in offices across Florida. Use our Find Your Provider Engagement Account Manager tool to locate the right person to assist you. You can also contact Provider Services at 1-844-477-8313 or email SunshineHealthProviderRelations@SunshineHealth.com.

Our Community Co-Stars Incentive Program rewards your ALF for helping members live in a community setting after they transition from a custodial nursing home. Living in a community setting helps members become more independent, allowing them the opportunity to make their own care decisions 

Effective April 1, 2025, ALFs can earn a bonus of $300 per qualifying member, per month. Qualifying members must reside in the ALF for a minimum of 16 days each month post nursing home transition during the year, defined as October 1 to September 30. Community Co-Star Incentive payments are issued quarterly. Talk to your Provider Engagement Account Manager or call Provider Services for more information.

Create an account and login to the Secure Provider Portal to:

• Verify member eligibility
• Submit and check claims
• Submit prior authorizations
• Check your incentive payments and more.

Find our Provider Billing Manual (PDF) and Assisted Living Facility Quick Reference Guide (PDF) to access step-by-step instructions to help you navigate forms. The LTC Claims Submission web page has additional billing guidelines.

Sunshine Health offers clinical trainings to support our Long Term Care Providers in delivering quality care to our members. Training topics are related to LTC, integrated care, and/or behavioral health:

• Advance Directives
• Abuse, Neglect and Exploitation of Vulnerable Adults
• Behavior Management
• Cultural Competency
• Depression in the Elderly
• De-escalation Techniques
• The Keys of Fall Prevention
• An Overview of Trauma-Informed Care When Working With Older Adults
• Substance Use Disorders: An Overview for Health Care Providers
• And More!

Register or find training in the “Long Term Care Clinical Provider Training” section of Provider Training.

Most claims are denied for easy-to-remedy reasons. Here are the most common reasons claims are denied and tips to help you ensure accurate and timely filings:

1. Not verifying member eligibility.
   • Use the Secure Provider Portal to verify member eligibility.
2. Claim form errors due to simple clerical errors or illegible handwriting.
   • Submit your claims in the Secure Provider Portal for faster processing.
3. Understanding patient responsibility and personal needs allowance.
   • Patient responsibility is the amount a member must pay for services not covered by Medicaid.
   • The amount of patient responsibility is determined by DCF and is based on income and choice of residence.
   • A member’s patient responsibility can affect the amount a provider is paid for services.
   • Sunshine Health delegates the collection of patient responsibility to the provider, so it is important to know what the member’s patient responsibility is per the DCF Notice of Case Action form.
   • Personal needs allowance is the amount of monthly income that an LTC member may keep to pay for personal expenses, including ALF room and board. This amount is determined by DCF.
4. Claim was filed after the filing deadline, which is 180 calendar days from the date of service.

Requests for claims reconsideration or adjustment must be received within 90 calendar days from the date of notification of payment or denial. Submit your request through the Secure Provider Portal or mail to:

Sunshine Health
Attn: Adjustments/Reconsiderations/Disputes
P.O. Box 3070
Farmington, MO 63640-3823