LTC Claims Submission

Physicians, other licensed health professionals, facilities, and ancillary provider’s contract directly with Sunshine Health for payment of covered services.

It is important that providers ensure Sunshine Health has accurate billing information on file. Please confirm with your Provider Relations Department that the following information is current in our files:

  • Provider Name (as noted on his/her current W-9 form)
  • Provider nine (9) digit Medicaid Number
  • Provider National Provider Identifier (NPI)
  • Physical location address (as noted on current W-9 form)
  • Billing name and address (if different)
  • Tax Identification Number

Providers must bill with their NPI number in box 24J of the HCFA 1500 if applicable. Sunshine Health will return claims when billing information does not match the information that is currently in our files. Claims missing the requirements in bold will be returned, and a notice sent to the provider, creating payment delays. Such claims are not considered “clean” and therefore cannot be entered into the system.

We recommend that providers notify Sunshine Health in advance of changes pertaining to billing information. Please submit this information on a W-9 form. Changes to a Provider’s Tax Identification Number and/or address are NOT acceptable when conveyed via a claim form.

Claims eligible for payment must meet the following requirements:

  • The Enrollee is effective on the date of service
  • The service provided is a covered benefit under the Enrollee’s contract on the date of service
  • Referral and prior authorization processes were followed

Payment for service is contingent upon compliance with referral and prior authorization policies and procedures, as well as the billing guidelines outlined in this manual.

Providers must submit, all claims and encounters within 180 days of the date of service, unless Sunshine Health or its vendors created the error. The filing limit may be extended for newborn claims, and where the eligibility has been retroactively received by Sunshine Health, up to a maximum of 365 days. When Sunshine Health is the secondary payer, Sunshine Health must receive the claim within ninety (90) days of the final determination of the primary payer.

All requests for reconsideration or adjustment to paid claims must be received within 90 calendar days from the date the notification of payment or denial is received.

Network providers are encouraged to participate in Sunshine Health’s Electronic Claims/Encounter Filing

Program. The plan has the capability to receive an ASC X12N 837 professional, institution or encounter

transaction. In addition, it has the ability to generate an ASC X12N 835 electronic remittance advice known as an Explanation of Payment (EOP). For more information on electronic filing, contact:

Sunshine State Health Plan
c/o Centene EDI Department
1-800-225-2573, extension 25525
or by e-mail at:
EDIBA@centene.com

Providers that bill electronically are responsible for filing claims within the same filing deadlines as providers filing paper claims.

Providers that bill electronically must monitor their error reports and evidence of payments to ensure all submitted claims and encounters appear on the reports. Providers are responsible for correcting any errors and resubmitting the affiliated claims and encounters.

Providers must be registered with Florida Medicaid.  Sunshine will take whatever steps are necessary to ensure that the provider is recognized by the state Medicaid program, including the enrollment broker contractor(s) as a participating provider of Sunshine Health Plan, and, that the provider’s submission of encounter data is accepted by the Florida MMIS and/or the state’s encounter data warehouse.

For participating providers who have internet access and choose not to submit claims via Electronic Data Interchange (EDI), Sunshine Health has made it easy and convenient to submit claims directly to us on our website.

You must request access to our Secure Provider Portal by registering for a user name and password and have requested Claims access. If you do not have an ID, sign up to obtain one today. Requests are processed within 2-business days.

There are five easy steps to submitting a claim. You may view web claims, allowing you to re-open and continue working on saved, un-submitted claims and this feature allows you to track the status of claims submitted using the website.

For Sunshine Health Enrollees, all claims and encounters should be submitted to:

Sunshine State Health Plan
P.O. BOX 3070
Farmington, MO 63640-3823
ATTN: CLAIMS DEPARTMENT

Sunshine Health uses an imaging process for claims retrieval. To ensure accurate and timely claims capture, please observe the following claims submission rules:

Do's

  • Do use the correct PO Box number
  • Do submit all claims in a 9” x 12”, or larger envelope
  • Do type all fields completely and correctly
  • Do submit on a proper original red claim form: CMS 1500 or UB 04

Don’ts

  • Don’t submit handwritten claim forms
  • Don’t circle any data on claim forms
  • Don’t add extraneous information to any claim form field
  • Don’t use highlighter on any claim form field
  • Don’t submit photocopied claim forms or black and white claim forms as they will not be accepted
  • Don’t submit carbon copied claim forms
  • Don’t submit claim forms via fax

A clean claim means a claim received by Sunshine Health for adjudication, in a nationally accepted format in compliance with standard coding guidelines and which requires no further information, adjustment, or alteration by the provider of the services in order to be processed and paid by Sunshine Health.

Non-clean claims are submitted claims that require further investigation or development beyond the information contained therein. The errors or omissions in claims result in the request for additional information from the provider or other external sources to resolve or correct data omitted from the bill; review of additional medical records; or the need for other information necessary to resolve discrepancies. In addition, non-clean claims may involve issues regarding medical necessity and include claims not submitted within the filing deadlines.

You are required to submit an encounter or claim for each service that you render to a Sunshine Health Enrollee.

  • If you are the provider for a Sunshine Health Enrollee and receive a monthly capitation amount for services, you must file a “proxy claim” (also referred to as an “encounter”) on a CMS 1500 for each service provided. Since you will have received a pre-payment in the form of capitation, the “proxy claim” or “encounter” is paid at zero dollar amounts. It is mandatory that your office submits encounter data.Sunshine Health utilizes the encounter reporting to evaluate all aspects of quality and utilization management, and it is required by the State of Florida and by Centers for Medicare and Medicaid Services (CMS).
  • A claim is a request for reimbursement either electronically or by paper for any medical service. A claim must be filed on the proper form, such as CMS 1500 or UB 04. A claim will be paid or denied with an explanation for the denial. For each claim processed, an Explanation of Payment (EOP) will be mailed to the provider who submitted the original claim.

Sunshine Health encourages all providers to file claims/encounters electronically. See “Electronic Claims Submission” for more information on how to initiate electronic claims/encounters.

Please remember the following when filing your claim/encounter:

  • All documentation must be legible.
  • All participating providers must submit claims or encounter data for every Enrollee within the timely filing limit which is 180 days of the date of service.  Medicare crossover claims must be submitted within 90 days after final determination of the primary payer which is not to exceed 3 years from the date of service.
  • Provider must ensure that all data and documents submitted to Sunshine Health, to the best of your knowledge, information and belief, are accurate, complete or truthful.
  • All claims and encounter data must be submitted on either an original form CMS 1500, UB 04, or by electronic media in an approved format. Copies of claim forms will not be accepted.
  • Review and retain a copy of the error report that is received for claims that have been submitted electronically, then correct any errors and resubmit with your next batch of claims.
  • All requests for reconsideration or adjustment to paid claims must be received within 90 days from the date the notification of payment or denial is received.
  • When submitting claims where other insurance is involved, a copy of the EOB or rejection letter from the other insurance carrier must be attached to the claim.
  • Sunshine Health Enrollees’ must never be billed by any provider forcovered services unless the criteria listed under “Billing the Enrollee” is met.
  • In a Worker’s Compensation case for which Sunshine Health is not financially responsible, the provider should directly bill the employer’s Worker’s Compensation carrier for payment.

Non-par providers only: 

  • Claims will not be denied based solely on the period between date of service and the date of clean claim submission unless that period exceeds 365 days.

For all contracts with reimbursement for services based on AHCA’s Medicaid fee for service rates, please note the following:

Any reference to the “Medicaid Fee-for-Service rates,” “Medicaid fee schedule,” “Medicaid state exempt rates” or similar term contained in any contract is a reference to the applicable fee schedule used by AHCA as of the date of service to determine payment under the Medicaid FFS Program.

Updates to such Medicaid fee schedules (for all provider types and in any form, including but not limited to, Medicaid Bulletins) shall become effective on the date (“Fee Change Effective Date”) that is the later of: (i) the first day of the month following thirty (30) days after publication by AHCA of such fee schedule updates, or (ii) the effective date of such fee schedule updates as determined by AHCA. Medicaid fee schedule rate revisions shall be applied by Sunshine Health.

All requests for claim reconsideration or adjustment must be received within 90 calendar days from the date of notification of payment or denial. Prior processing will be upheld for reconsiderations or adjustments received outside of the 90 day timeframe, unless a qualifying circumstance is offered and appropriate documentation is provided to support the qualifying circumstance. Qualifying circumstances include:

  • Catastrophic event that substantially interferes with normal business operations of the provider or damage or destruction of the provider’s business office or records by a natural disaster.
  • Pending or retroactive Enrollee eligibility. The claim must have been received within 6 months of the eligibility determination date.
  • Mechanical or administrative delays or errors by Sunshine Health or AHCA.
  • The Enrollee was eligible however the provider was unaware that the Enrollee was eligible for services at the time services were rendered.

Consideration is granted in this situation only if all of the following conditions are met:

  • The provider’s records document that the Enrollee refused or was physically unable to provide their Medicaid card or information.
  • The provider can substantiate that a claim was filed within 180 days of discovering Medicaid Plan eligibility.
  • No other paid claims filed by the provider prior to the receipt of the claim under review.

When submitting a paper claim for review or reconsideration of the claims disposition, a copy of the EOP must be submitted with the claim, or the claim must clearly be marked as “RE-SUBMISSION and include the original claim number.” Failure to boldly mark the claim as a resubmission and include the claim number (or include the EOP) may result in the claim being denied as a duplicate, or for exceeding the filing limit deadline. Download a claim disbute form (PDF).

Mail Requests for Reconsideration to:

Sunshine State Health Plan
Attn: LTC Reconsideration
PO Box 4001
Farmington, MO 63640‐4401

Providers may submit in writing, with all necessary documentation, including the EOP for consideration of additional reimbursement.

A response to an approved adjustment will be provided by way of check with an accompanying EOP.

All disputed claims will be processed in compliance with the claims payment resolution procedure as described in this Provider Billing Manual (PDF).

In order to avoid rejected claims or encounters always remember to:

  • Always bill the primary diagnosis in the first field
  • Use the CPT-4 or billing codes found on the authorization or referral.
  • Submit all claims/encounters with the proper provider NPI and /or Tax ID Number
  • Submit all claims/encounters with the Enrollee’s complete Medicaid number