Manuals, Forms and Resources
Manuals
Claims Related Forms
General Provider Forms
- Inpatient Prior Authorization Fax Form (PDF)
- Outpatient Prior Authorization Fax Form (PDF)
- Notification of Pregnancy Form (PDF)
- Prior Authorization List
- Provider Education – Marketing (PDF)
- Risk Adjustment (PDF)
- Durable Medical Equipment Home Health and Home Infusion Referral Form (PDF)
- Authorization for Private Duty Nursing Provided by a Parent or Legal Guardian (PDF)
BMI Graph Tool
Advance Directives
Florida Health Care Association - Health Care Advanced Directives
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PaperFree Florida
Claims Related Forms
- Provider Dispute Form (PDF)
- Multiple Claim Submission Wizard-LTC (PDF)
- How to Complete CMS UB-04 Claim? (PDF)
- W-9 Form (PDF)
Helpful Links
- Assisted Living Facilities Supports and Resources
- The Florida Department of Elder Affairs
- Florida Association of Assisted Living
- DCF
- Veterans Affairs
- Social Security Administration
- Department of Elder Affairs
- Medicare
- My Florida
- AHCA Nursing Home Rates
- Hospice
- Florida Health Finder
Provider Services and Complaints Policy
Provider Services and Complaints Policy (PDF)
General Forms
Provider Manual
Billing Manual
Medicaid Provider Billing Manual (PDF)
In Lieu of Services Resource Guide
The Medicaid In Lieu of Services Resource Guide (PDF) describes the ILOS benefits, eligibility requirements, limits and prescribing rules.
Claims Related Forms
General Provider Forms
- Inpatient Prior Authorization Fax Form (PDF)
- Outpatient Prior Authorization Fax Form (PDF)
- Notification of Pregnancy Form (PDF)
- Connections Referral Form (PDF)
- Prior Authorization List
- Provider Education – Marketing (PDF)
- Risk Adjustment (PDF)
- Durable Medical Equipment Home Health and Home Infusion Referral Form (PDF)
- Authorization for Private Duty Nursing Provided by a Parent or Legal Guardian (PDF)
HEDIS
- HEDIS Quick Reference Guide (PDF)
- HEDIS Tip Sheet – Adult Measures (PDF)
- HEDIS Tip Sheet – Pediatric Measures (PDF)
- HEDIS Tip Sheet – Well Women Measures (PDF)
BMI Graph Tool
PaperFree Florida
Training
- Provider Manual (PDF)
- Envolve Pharmacy SolutionsTM Prior Authorization Request Form (PDF)
- Provider Education – Marketing (PDF)
- Prior Authorization List (PDF)
- National Imaging Associates, Inc. (NIA)
- Inpatient Prior Authorization Fax Form (PDF)
- Outpatient Prior Authorization Fax Form (PDF)
- Notification of Pregnancy Form (PDF)
Immunizations
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.
Provider Manuals and Guides
- Provider and Billing Manual - Medicare Advantage (PDF)
- Quick Reference Guide (PDF)
- Allwell from Sunshine Health Provider Toolkit (PDF)
Claims and Payments
Billing
- PaySpan – EFT/ERA
Allwell from Sunshine Health is pleased to partner with PaySpan Health to provide an innovative web based solution for Electronic Funds Transfers (EFTs) and Electronic Remittance Advices (ERAs). This service is provided at no cost to providers and allows online enrollment.
Visit PaySpan’s website for more information - Provider Portal
If you are a contracted provider, you can register now. View detailed instructions on how to register (PDF). If you are a non-contracted provider, you will be able to register after you submit your first claim. - Sunshine Health Payment Policies
Provider Payment forms
Medical Management
Prior Authorization Resource
- Medicare Pre-Auth
DISCLAIMER: All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent upon eligibility, covered benefits, provider contracts and correct coding and billing practices. For specific details, please refer to the Allwell from Sunshine provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
Authorization Forms
Authorization requests may be submitted by secure web portal and should include all necessary clinical information.
- Medicare Advantage Prior Authorization List - English (PDF)
- Medicare Advantage Prior Authorization List - Spanish (PDF)
- Elective Inpatient Prior Authorization Form (PDF)
- Outpatient Prior Authorization Form (PDF)
- Please Fax Current Admission and Clinical information to the below:
- Current Admissions 1-877-808-9369
- Clinical Information 1-866-796-0527
- Please Fax Current Admission and Clinical information to the below:
- Durable Medical Equipment (DME), Home Health & Home Infusion Referral Form (PDF)
- National Imaging Associates (NIA)
Quality of Care
- HEDIS Quick Reference Guide (PDF)
- HEDIS Tip Sheet – Adult Measures (PDF)
- HEDIS Tip Sheet – Pediatric Measures (PDF)
- HEDIS Tip Sheet – Well Women Measures (PDF)
BMI Graph Tool
For Ambetter information, please visit our Ambetter website.