LTC Frequently Asked Questions

AHCA has the lead on the entire SMMC program and will contract with the health plans for the delivery of SMMC long term care services. Additionally, DOEA is responsible for monitoring quality assurance components.

DOEA’s CARES program will remain responsible for determining medical eligibility (i.e., level of care) for recipients wishing to enroll in the new program. Contact Provider Services at 866-769-1158 for specific locations and phone numbers.

Sunshine State’s case managers will work with you to transition the recipient to other providers. You may be asked to provide care plans and service information. You will only receive reimbursement if you have a written contract or agreement with the plan they chose.

Always contact your Case Manager regarding any transitions.

Prior authorization is required for all Long Term Care services except Emergency and post stabilization services.  Sunshine State’s Case Managers authorize all services and prepare Care Plans for ALFs.  Requests can be obtained by calling Medical Management/Case Management at:

1-866-769-1158 (Prior auth fax)
1-877-505-0825 (Case mgt. fax)
Or at: www.sunshinestatehealth.com

Providers who are part of Sunshine State’s network will be reimbursed for covered services, assuming the Enrollee is eligible on the date(s) of service and services have been authorized prior to the service being rendered, according to contracted fees and members should not be billed for covered services.

Electronic claims can be submitted via Electronic Data Interchange (EDI) or via the internet. Sunshine State Health Plan has made it easy and convenient to submit claims directly to us on our website at  www.sunshinestatehealth.com.   EDI vendors are listed on the Providers Quick Reference Guide or contact Provider Services for more information.

Submit claims for professional services and durable medical equipment on a CMS 1500. A UB 04 is the only acceptable claim form for submitting nursing home services. Incomplete or inaccurate information will result in the claim being rejected or denied for corrections.

Payments are expedited when claims are submitted electronically. Clean claims will be adjudicated (finalized as paid or denied) within twenty (20) days if electronically submitted (10 days for Nursing Homes) vs. forty (40) days when submitted on paper (only red originals will be accepted) from the receipt of the claim.  All participating providers must submit claims within 180 days from service date.

Providers can also take advantage of direct deposit services through PaySpan. The process is easy and you may enroll for direct deposit by calling 1-800-733-0908 or you may register online at www.payspanhealth.com.

Eligibility will be verified by Sunshine State prior to issuing authorizations.  Providers should verify eligibility for ongoing services via www.sunshinestatehealth.com or through the Interactive Voice Response (IVR) system at 877-211-1999. The IVR is available 24 x 7 for eligibility and claims status.

Existing services for eligible members, will continue unabated for up to 60 days, OR until the recipient receives a comprehensive assessment and a new plan of care is developed. Sunshine State MAY choose to use you to deliver these services. If you are authorized by the plan to provide services, you should not bill FMMIS.

Call 1-866-769-1158, choose option 2 for providers and then option 5, between 8 am and 7 pm, Monday through Friday for all provider inquiries.