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Provider Quick Reference Guide

Providers can visit the Sunshine Health website at SunshineHealth.com to access the following:

  • Provider manuals, forms, directories
  • Provider training materials
  • “Pre-Authorization Needed?” tool
  • Companion guide for electronic transactions
  • Child health checkup/EPSDT information
  • PaySpan Health for EFTs/ERAs
  • Sunshine Health Provider News
  • Clinical guidelines
  • Clinical resources on Evidence Based Practices
  • Fraud, Waste and Abuse training for providers

The following information is available via the website by logging into the secure portal:

  • PCP verification
  • Member eligibility/verification
  • PCP cost reports
  • Claims submission/inquiry/adjustment
  • Request Prior Authorization (PA)

Contact the Sunshine Health Provider Services Department, 8 a.m. to 8 p.m. EST/EDT, Monday-Friday, at 1-844-477-8313 or fax 1-866-614-4955 for assistance with the following services:

  • Questions about claim/credentialing/network status
  • Request for adding physicians to an existing group
  • Request a free copy of our Provider Manual

HEDIS Measures: Sunshine Health calculates and reports HEDIS measures annually. HEDIS consists of 20+ Effectiveness of Care type measures as well as Access to Care and Use of Services measures for which the Plan contractually reports rates to the State of Florida based on claims and/or medical records review data.

Measures include: Effectiveness of Care, Access and Availability, Satisfaction with the Experience of Care, Use of Services, Cost of Care, Health Plan Descriptive Information and Health Plan Stability.

Periodicity for Well Child Visits:

  • Birth exam
  • 2 to 4 days (if newborn is discharged in less than 48 hours)
  • By 1 month
  • 2 months
  • 4 months
  • 6 months
  • 9 months
  • 12 months
  • 15 months
  • 18 months
  • Once per year from age 2 through 20

Electronic Data Interchange (EDI)

EDI support for HIPAA transactions is provided by Sunshine Health’s corporate office, Centene Corporation. For support, please contact our EDI Department at 1-800-225-2573, ext. 25525, or visit our website at

SunshineHealth.com. The website contains our electronic Billing Manual which offers detailed information regarding claims billing instructions, requirements for the CMS 1500/837 Professional, and the UB04/837 facility claim forms. Sunshine Health’s Payer ID is 68069.

Reconsiderations and Disputes

All requests for claims reconsideration or adjustment must be received within 90 calendar days from the date of notification of payment or denial (please refer to the provider manual for information regarding qualifying circumstances). Submit claim reconsiderations or adjustments through our secure web portal or mail to:

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

Timely Filing Guidelines

Initial Filing: 180 calendar days of the date of service Coordination of Benefits (Sunshine Health as Secondary); 180 calendar days of the date of service or 90 calendar days of the primary payer’s determination (whichever is later). Corrected/Reconsideration/Dispute : 90 calendar days from the payment/denial notification.

The Sunshine Health Medical Management team provides oversight of utilization management, case management and care coordination. Authorization must be obtained prior to the delivery of certain elective and scheduled services and can be submitted through the web portal or via fax. The new PA form is located at: SunshineHealth.com, “For Providers” then “Provider Resources.” Open the specific inpatient or outpatient PDF file and fill in the fields. Save the file as a new document, print the form and fax it to 1-866-796-0526. Please use a new online form for each request.

Medical Management/Case Management

  • 1-866-796-0530 Monday–Friday, 8 a.m. to 7 p.m. EST/EDT
  • 1-866-796-0526 (PA Fax)
  • 1-877-689-1056 (Case Management Fax)
  • 1-866-694-3649 (Behavioral Health PA Fax)

PA Requests

  • Inpatient non-emergent admissions (elective)
  • Physician office requests for plan approval
  • Inpatient emergent or urgent admissions
  • Hospital notifies Health Plan within 2 days of admission
  • Newborn deliveries – Notification to Health Plan next business day
  • Observation admission – Notification within the first 48 hours
  • Out-Of-Network – Notification following stabilization of emergency care

Members may call Sunshine Health to select and/or change their PCP assignment at any time. Members may also request language assistance or help with other issues.

Member Services department

  • 1-866-796-0530 Monday–Friday,
  • 8 a.m. to 8 p.m. EST/EDT
  • 1-866-796-0523 (Member Services Fax)
  • 1-800-955-8770 (TDD/TYY)

Provider Services Line

  • 1-844-477-8313 (Effective: Dec. 1, 2018)