Manuals, Forms and Resources

Important Provider Notifications

Sunshine Health Advantage (HMO SNP) is publishing its Payment and Clinical Policies to inform providers about acceptable billing practices and reimbursement methodologies for certain procedures and services. For more information, click the Important Provider Notification.

Sunshine Health Opioid Summit Toolkit

Click here for the complete Sunshine Health Opioid Summit Toolkit.

Forms and Resources

Provider Manuals

Payment Policy

Claims Related Forms

General Provider Forms

Medicare Advantage Resources

Preventive and Clinical Practice Guidelines

HEDIS Quick Reference Guide

HEDIS Tip Sheets

BMI Graph Tool

Fraud, Waste and Abuse

Provider Training


Children must be immunized during medical checkups according to the in accordance with the ACIP periodicity table by age and immunizing agent.

An assessment of the child’s immunization status should be made at each screening and immunizations administered as appropriate.  If the child is due for an immunization, it must be administered at the time of the screening.  However, if illness precludes immunization, the reason for delay should be documented in the child’s record.  An appointment should be given to return for administration of immunization at a later date.

Immunization of children should be provided according to the guidelines recommended the Centers for Disease Control (CDC), the Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics, and Florida State Law.

NOTE: HEALTHY KIDS MEMBERS ARE NOT ELIGIBLE FOR THE VACCINES FOR CHILDREN PROGRAM (VFC).  BILL SUNSHINE HEALTH FOR THE VACCINE AS WELL AS THE ADMINISTRATION OF THE VACCINE(Administration fee inclusive of the Vaccine Reimbursement).  Even though the VFC program does not apply to Healthy Kids members, all providers are required to participate in the Fl SHOTS immunization registry.  

PCP Toolkit for Behavioral Health

Includes information and patient resources on ADHD, Anxiety, Depression and Substance Use Disorder.

ADHD Toolkit

Attention Deficit Hyperactivity Disorder Facts

Best-Practice Intervention Strategies

  • Educate parents on ADHD management
  • Increase parent/child symptom awareness
  • Parental tracking of assignments, chores, and home responsibilities
  • Rule out comorbid disorders
  • Assess for possible presence of parental psychopathology interfering with treatment
  • Take prescribed medications consistently and monitor for side effects
  • Maintain communication with school to increase compliance on assignments
  • Develop and utilize effective study skills
  • Delay instant gratification in pursuit of long-term goals
  • Develop increased anxiety management skills and self-confidence
  • Develop effective problem-solving skills
  • Increase verbalization of acceptance of responsibility for behaviors
  • Identify stressors and emotions that trigger hyperactivity and impulsivity
  • Identify constructive outlets for energy

Citations: Journal of the American Academy of Child & Adolescent Psychiatry 2007 Jul; 46(7):894- 921. The Child Psychotherapy Treatment Planner, 4th Edition, 2006, Arthur E. Jongsma, Jr., L. Mark Peterson, William P. McInnis, Timothy J. Bruce, Ph.D. (Contributing Editor) Websites Children Youth and Families Mental Health Evidence Based Practice Project. SUNY: University at Buffalo, School of Social Work. Clinical Practice Guideline: Treatment of the school-aged child with attention-deficit hyperactivity disorder:;108/4/1033 Therapy Advisor:

Anxiety Toolkit

Anxiety and OCD Best Practice Intervention Strategies


  • Participate in a medical evaluation to rule out any medical conditions that may be causing or contributing to anxiety
  • Participate in a psychiatric evaluation and take all medications as prescribed
  • Develop and practice positive coping skills to manage stress and anxiety (Such as adequate rest, proper nutrition, physical exercise and recreational activities/hobbies)
  • Practice relaxation techniques such as deep breathing and guided imagery
  • Learn to recognize the difference between emotional and physical reactions to anxiety
  • Participate in systematic desensitization of feared stimuli while practicing relaxation strategies
  • Identify a social support team and increase participation in social activities
  • Identify negative self-talk and replace with positive statements
  • Involve family members in psycho-education about anxiety to increase understanding and support
  • Recognize, verbalize and address unresolved emotional issues

Obsessive Compulsive Disorder

  • Participate in a psychiatric evaluation and take all medications as prescribed
  • Use a thought stopping strategy to interrupt cognitive obsessions
  • Practice relaxation techniques such as deep breathing
  • Consider learning and practicing the Exposure and Response Prevention (ERP) technique by confronting feared situations and objects (exposure) and resist performing compulsive rituals (response prevention)
  • Recognize, discuss, and refute dysfunctional beliefs (e.g., magical or catastrophic thinking patterns)
  • Develop and practice a daily ritual to interfere with the current compulsive pattern
  • Identify, verbalize and address unresolved life issues
  • Provide psycho-education for family members and encourage their support for the patient during treatment
  • Develop and practice positive self-talk
  • Anxiety ToolkitOverview
  • GAD7 Anxiety Screening tool
  • Med Guide Anxiety

Substance Use Disorder Toolkit

Alcohol and Other Drug Facts

Assessment Components

The six ASAM Placement Criteria dimensions:

  • transmissible infectious diseases and other bio-medical history (provide targeted risk-reduction counseling as indicated)
  • co-occurring mental health or behavioral problems (ensure concurrent AOD and mental health treatment, as indicated)
  • potential for withdrawal symptom severity and the need for medications
  • motivation for change (using the Prochaska Stages Of Change model)
  • protective factors and risk factors in the recovery environment
  • potential for relapse

Treatment Components

  • Drug testing during treatment to provide incentive for, and monitor, abstinence
  • Utilize Motivational Interviewing as part of a non-confrontational, solution focused approach to treatment engagement and retention in order to facilitate optimum outcomes 
  • Consider age, gender, maturity/developmental level, and culture in all phases of assessment, treatment and service delivery
  • Education regarding the effects of substance use, what to expect in the course of treatment, and the expected effects of treatment
  • Open-ended questions and exploration of values, past successes, and empathic reflection of thoughts and feelings to support self-realization of the need for change
  • Identification of routine triggers for substance use and understanding relapse as a process
  • Identification and modification of social and other barriers to abstinence
  • Support for self-efficacy, effective coping and problem-solving skill sets for current and future stressors
  • Inclusion of the relevant support system (e.g., family members) in both
  • Substance Use Disorder ToolkitOverview
  • AUDIT Screener for Alcohol
  • CAGE-AID Screening Tool

Home Health and Durable Medical Equipment Providers

Learn how to maximize reimbursement opportunities by correctly documenting procedure codes and reduce the risk of claims denials. To learn more, click on the Billing and Procedure Coding Guide

Ambetter Manuals & Forms

For Ambetter information, please visit our Ambetter website.

Provider Education

Generalized Anxiety Disorder

Generalized Anxiety Disorder, GAD, is an anxiety disorder characterized by chronic anxiety, exaggerated worry and tension, even when there is little or nothing to provoke it.

Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Repetitive behaviors such as hand washing, counting, checking, or cleaning are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these so-called “rituals,” however, provides only temporary relief, and not performing them markedly increases anxiety.

Panic Disorder

Panic disorder is an anxiety disorder and is characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, and shortness of breath, dizziness, or abdominal distress.

Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) PTSD is an anxiety disorder that some people get after seeing or living through a dangerous event. When in danger, it’s natural to feel afraid. This fear triggers many split-second changes in the body to prepare to defend against the danger or to avoid it. This “fight-or-flight” response is a healthy reaction meant to protect a person from harm. But in PTSD, this reaction is changed or damaged. People who have PTSD may feel stressed or frightened even when they’re no longer in danger.

Social Phobia (or Social Anxiety Disorder)

Social Phobia, or Social Anxiety Disorder, is an anxiety disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. Social phobia can be limited to only one type of situation — such as a fear of speaking in formal or informal situations, or eating or drinking in front of others — or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people.

Best Practices

Interventions for the treatment of anxiety disorders categories: Pharmacological and psychosocial interventions. Cognitive behavior therapy (CBT) is a type of psychosocial treatment that helps patients to understand the thoughts and feelings that influence behaviors. Pharmacological management includes, most often, prescribing an Antidepressant, anti-anxiety medications, and beta-blockers.

Screening Tools:

  • GAD-7
  • Anxiety Rating Test, Social Anxiety Test, Anxiety Potential Test, Anxiety Disorder Test, and Degree of Anxiety Condition Test


Autism is one of a group of serious developmental problems called autism spectrum disorder (ASD) that appear in early childhood- usually before age 3. Though symptoms and severity vary, all autism disorders affect a child’s ability to communicate and interact with others.

Symptoms to look for:

Problems in three crucial areas of development: social interaction, language and behavior.

  • Fails to respond to his or her name
  • Has poor eye contact
  • Appears not to hear you at times
  • Resists cuddling and holding
  • Appears unaware of others’ feelings
  • Seems to prefer playing alone
  • Starts talking later that age 2
  • Loses previously acquired ability to say words or sentences
  • Doesn’t make eye contact when making requests
  • Speaks with an abnormal tone or rhythm
  • May repeat words of phrases verbatim
  • Performs repetitive movements such as rocking, spinning, or hand flapping
  • Develops specific routines or rituals
  • Becomes disturbed at the slightest change in routine or rituals
  • Moves constantly
  • May be unusually sensitive to light, sound and touch and yet oblivious to pain
  • May be fascinated by parts of an object, such as the spinning wheels of a toy car

Best Practices:

No cure exists for autism, and there is no “one–size-fits-all” treatment. The range of home-based and school-based treatments and interventions of autism can be overwhelming. Treatment options may include: behavior and communications therapies, educational therapies and medications. Alternative therapies include: creative therapies, special diets, and chelation therapy.

Screening Tools:

  • Due to the complex nature of autism, numerous screening tools exist. Here are some of the links that can be used for screening purposes.


Bipolar Disorder is a condition characterized by shifts in mood, energy, and activity levels, which can affect one’s ability to carry out daily tasks as well as one’s relationships, job, and school performance. Individuals suffering from Bipolar Disorder experience distinct “mood episodes” that are more extreme than the regular ups and downs that we may all experience from time to time. There are multiple types of Bipolar Disorder that differ in the types of mood episodes experienced, as well as the frequency and intensity of the symptoms. Bipolar Disorder often develops in the late teens or early adult years, but in some cases can begin in childhood or later in one’s adult life. It is usually a long term illness, but there are effective treatments that can allow people to lead full and productive lives.

Symptoms to look for:

Signs of a Manic Episode:
  • Excessive happiness or excitement
  • Irritability
  • Restlessness or increased energy
  • Racing thoughts
  • Grandiosity
  • Impulsive or reckless behaviors
Signs of a Depressive Episode:
  • Sadness
  • Decreased energy or motivation
  • Difficulty concentrating
  • Hypersomnia
  • Appetite changes
  • Hopelessness

Best Practices

Often, people respond best to a combination of medication and therapy aimed at learning to manage symptoms. There are a variety of medications used to treat Bipolar Disorder and people may need to try different types before they find that ones that work best for them. Mood stabilizers, anticonvulsants, and antipsychotics are often used to treat this disorder. In addition, the depressive symptoms may be treated with antidepressants, but are usually taken with a mood stabilizer due to the risk of triggering a manic episode. Individuals with Bipolar Disorder are also at high risk for suicide whether they are in a manic or depressive episode, so it is important to assess for this and plan for emergencies.

Screening Tools:

  • The Mood Disorders Questionnaire


Borderline personality disorder is a serious mental illness marked by unstable moods, behavior, and relationships. Because some people with severe borderline personality disorder have brief psychotic episodes, experts thought of this illness as atypical, or borderline, versions of other mental disorders. While mental health experts now generally agree that the name “borderline personality disorder” is misleading, a more accurate term does not exist yet. Most people who have borderline personality disorder suffer from:

  • Problems with regulating emotions and thoughts
  • Impulsive and reckless behavior
  • Unstable relationships with other people.

People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides. Other illnesses that often occur with BPD include diabetes, high blood pressure, chronic back pain, arthritis, and fibromyalgia. These conditions are associated with obesity, which is a common side effect of the medications prescribed to treat borderline personality disorder and other mental disorders.

Symptoms to look for:

  • According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:
  • Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
  • A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
  • Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
  • Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
  • Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
  • Intense and highly changeable moods, with each episode lasting from a few hours to a few days
  • Chronic feelings of emptiness and/or boredom
  • Inappropriate, intense anger or problems controlling anger
  • Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

Best Practices

Psychotherapy is usually the first treatment for people with borderline personality disorder. Types of psychotherapy include Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT) and Schema-focused therapy.

Screening Tools:

  • The McLean Screening Instrument


Depression is a medical illness that involves the mind and body. It affects how someone feels, thinks and behaves. It can lead to a variety of emotional and physical problems. Someone may have trouble doing normal day-to-day activities, and depression may make someone feel as if life isn’t worth living. More than just a bout of the blues, depression isn’t a weakness, nor is it something that someone can simply “snap out” of. Depression is a chronic illness that usually requires long-term treatment but most people with depression feel better with medication, psychological counseling or other treatment.

Symptoms to look for:

  • Persistent sad, anxious, or “empty” feelings
  • Feelings of hopelessness or pessimism
  • Feelings of guilt, worthlessness, or helplessness irritability, restlessness
  • Loss of interest in activities or hobbies once pleasurable
  • Fatigue and decreased energy
  • Difficulty concentrating, remembering details, and making decisions
  • Insomnia, early-morning wakefulness, or excessive sleeping
  • Overeating, or appetite loss
  • Thoughts of suicide, suicide attempts
  • Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.
Children and Adolescents
  • Frequent sadness, tearfulness, crying
  • Decreased interest in activities; or inability to enjoy previously favorite activities
  • Hopelessness
  • Persistent boredom; low energy
  • Social isolation, poor communication
  • Low self-esteem and guilt
  • Extreme sensitivity to rejection or failure
  • Increased irritability, anger, or hostility
  • Difficulty with relationships
  • Frequent complaints of physical illnesses such as headaches and stomachaches
  • Frequent absences from school or poor performance in school
  • Poor concentration
  • A major change in eating and/or sleeping patterns
  • Talk of or efforts to run away from home
  • Thoughts or expressions of suicide or self-destructive behavior

Best Practices

Interventions for the treatment of depression falls into two main categories: Pharmacological and psychosocial interventions. Psychosocial interventions such as Cognitive Behavioral Therapy, Interpersonal Therapy, Psychodynamic Therapy, and Dialectical Behavior Therapy, can be useful. Pharmacological management includes, most often, prescribing Antidepressants- including SSRI’s, SNRI’s, MAOI’s, Atypical, Tricyclic and Tetracyclic. A follow up appointment should occur within 12 weeks of diagnsosing and initiating treatment of an adult with an antidepressant medication. Another follow up appointment should occur within the next 90 days to ensure effective continuation of treatment.

Screening Tools:

  • PHQ-9


Psychosis is used to describe conditions that affect the mind in which there has been some loss of contact with reality. Some of the diagnostic psychotic disorders identified in the DSM IV TR are: Schizophrenia, Schizoaffective, Delusional Disorder, Brief Psychotic Disorder, Substance Induced Psychotic Disorder, and Psychotic Disorder NOS. Consider the following:

  • Symptoms usually start between ages 16- 30. Men tend to experience symptoms a little earlier than women.
  • Has the patient had a major traumatic event happen in his/her life?
  • Is there family history of mental illness?

Symptoms to look for:

  • Hallucinations auditory and visual are most common
  • Delusions
  • Social withdrawal
  • Reduced concentration and attention
  • Sleep disturbances
  • Irritability
  • Suspiciousness
  • Not caring for ADL’s
  • Anedonia (lack of interest)

Best Practices

Interventions for the treatment of schizophrenia and other psychotic disorders falls into two main categories: Pharmacological and psychosocial interventions. Pharmacological management includes, most often, prescribing a typical and/or atypical antipsychotic when a person is experiencing psychotic symptoms. Psychosocial interventions such as cognitive behavioral therapy (CBT), family therapy, or education, and problem solving therapy, can be useful in management of recovery and the prevention of relapse.

Screening Tools:


Somatoform disorders are a category of mental illnesses that cause pain or other symptoms that would suggest a medical condition but where no physical explanation can be found. These symptoms must cause the patient significant distress or impairment in functioning. Somatoform disorders differ from malingering in which symptoms are intentionally feigned for external gain, or factitious disorder in which symptoms are adopted or exaggerated due to an unconscious desire for sympathy or other internal gain. In somatoform disorders, the sufferer perceives the illness as real and they can cause the person to become extremely worried and preoccupied with their physical health. The types of somatoform disorders include Somatization Disorder, Pain Disorder, Hypochondriasis, Body Dysmorphic Disorder, and Conversion Disorder.

Symptoms to look for:

  • Physical pain with no apparent cause
  • Multiple symptoms occurring in different organ systems
  • Symptoms affecting motor or sensory function that are preceded by a psychological stressor
  • Preoccupation with fears of having a serious illness
  • Obsessions over physical imperfections or deformity that may or may not exist.

Best Practices

Diagnosing somatoform disorders can be difficult and requires a thorough medical examination and review of medical records to rule out any possible physical cause. Treatment for somatoform disorders should include therapy, and cognitive behavioral therapy has been shown to be one of the more effective treatments. Ongoing medical treatment is also necessary and psychosocial interventions guided by the physician seem to be most successful. A good relationship between the primary care physician is critical and psychoeducation about how symptoms can be exacerbated by stress and other psychological disturbances can help as well. Regular follow up visits and ongoing assessment of the patient’s condition will help reduce anxiety and limit emergency visits.

Screening Tools:

  • SOMS-7


Substance Abuse is the excessive consumption or misuse of a substance for the sake of its nontherapeutic effects on the mind or body, especially drugs or alcohol.

Possible signs of substance abuse:

  • Behavioral Changes: agitation, fits of violence or anger, paranoia or depression, apathy, forgetfulness, sudden need for money, lying
  • Physical Changes: any dramatic increase or decrease in weight, poor coordination, tremors, scent of substance, insomnia or hypersomnia
  • Social Changes: will withdraw from friends and family, suddenly socialize with those significantly younger or older

Best Practices

Current research-based best practices tend to merge the biopsychosocial, theoretical perspective of addictive disorders. This includes supportive counseling, motivating client readiness for change, and coping-skills training techniques. The goals of treatment are:

  • To establish and maintain abstinence from the illicit use of all psychoactive drugs;
  • To foster development of (non-chemical) coping and problem-solving skills;
  • To stop and ultimately eliminate impulses to “self-medicate” with psychoactive drugs; and
  • To enhance and sustain client motivation for change.

Screening Tools:

  • Screening for Drug Use in General Medical Settings(Quick Reference Guide)
  • Patient Health Questionnaire (PHQ)