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Assisted Living Facilities Supports and Resources

We appreciate your service and dedication to our Long Term Care members. Your personalized care improves their quality of life and enables them to live as independently as possible. We’re proud to be your partner in care.

Every Long Term Care member is assigned a Care Coordinator that will visit your facility to meet with our members and with you so we can work together to serve our members. We are here to support you with care coordination, provider support, member services, billing, payment, benefit questions and more.

 

Provider Services

1-844-477-8313
Monday-Friday from 8 a.m. to 8 p.m. (Eastern)

 

NEW! Value Based Incentive Program

Our Community Success Co-Stars Program rewards Assisted Living Facilities (ALFs) for helping our members live in a community setting after they transition from a custodial nursing home. ALFs can earn a $600 quarterly bonus for each qualifying member who resides in your facility for a continuous three-month period during the period of Oct. 1, 2019, to Sept. 30, 2020. Talk to your Sunshine Health representative or call Provider Services for more information.

 

Secure Provider Portal

Your one-stop shop to verify member eligibility, submit and check claims, submit prior authorizations, check your incentive payments and more. Create an account and log in. Once enrolled you will receive an email with information on all of the features of the site and be able to access a user manual after you log in.

 

More Resources

Our Provider Billing Manual (PDF) has step-by-step instructions with visuals to help you navigate forms. The LTC Claims Submission web page has additional billing guidelines.

Sunshine Health offers trainings for Long Term Care network providers. These trainings cover mostly LTC and behavioral health provider topics to improve member outcomes, such as:

  • Abuse, Neglect, Exploitation and Reporting Adverse Incidents
  • How to Handle an Urgent and Emergent Behavioral Health Situation (Baker Act)
  • Behavioral Health 101 Modules
  • Cultural Competency
  • De-Escalation Techniques
  • Depression and the Elderly
  • Understanding The Basics of Dementia

Register or find more information about Provider Training.

 

Claims Submission Tips

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.
  2. Claim form errors due to simple clerical errors or illegible handwriting. For example, member’s name was misspelled or digits in a Member ID number were transposed.
  3. Understanding patient responsibility and personal needs allowance.
    • Patient responsibility is the cost of Medicaid Long Term Care services not covered by Medicaid, which the member must pay. The amount of patient responsibility is determined by the Department of Children and Families (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.

 

Reconsiderations and Disputes

Requests for claims reconsideration or adjustment must be received within 90 calendar days from the date of notification of payment or denial. These may be submitted through our Secure Provider Portal or mailed to:

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