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Your Guide to Sunshine Health Provider Support: Finding the Right Contact

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For the Fastest Service: Use Our Secure Provider Portal 

Before calling or emailing, we encourage you to use our Secure Provider Portal. It's the quickest way to get real-time information and is available 24/7. You can instantly:

  • Check member eligibility and benefits
  • View and track claim status
  • Submit and check the status of prior authorizations
  • Access and download provider documents and remittance advice

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How to Ensure a Quick Resolution 

For inquiries that cannot be resolved through the portal, reaching the correct department directly is the key to a speedy resolution. To help us assist you as efficiently as possible, please have the following information ready when you contact us:

  • Provider's National Provider Identifier (NPI) and/or Tax ID Number (TIN)
  • Member's ID Number and date of birth
  • Claim Number (for claim-specific inquiries)
  • Date(s) of service

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Contacting the Right Department

Our teams specialize in handling specific types of inquiries. Sending an inquiry to the wrong department, or including multiple mailboxes on one email, will unfortunately delay our ability to provide you with a timely response.

Please use the grid below to identify the correct contact for your questions. This ensures your question is routed to the correct, specialized team from the start.

How to Connect with Us

This guide is designed to help you avoid delays and ensure your questions are answered by the team best equipped to handle them. For a successful and productive interaction, please review the issue types below to find the most relevant contact method. This will help our specialized teams provide a more effective resolution to your inquiry.

Quick link: Claims Template (xlsx)

Requirements: Billing NPI, Claims Template, Date(s) of Service, Medical Records - if applicable, Previous Ticket Number(s) - if applicable, Rendering NPI, Tax ID Number

Notes

  • A reconsideration is the initial step a provider should take when disputing the original processing or resolution of a claim that has reached final adjudication to request informal review and possibly correct the original processing of a claim. This initial step providers a quick review that can take up to 30 days to complete.
  • A dispute is the secondary step a provider should take if there is a dispute with the original reconsideration of the claim. This provides secondary review of the claim with a more complex review. This step can take up to 60 days to complete.
  • An appeal is a formal, structured process to challenge a denial or unfavorable decision after the claim has been fully adjudicated, reconsidered, and/or disputed. Appeals usually require supporting documentation, medical records, and a written argument. Subject to strict timelines and regulations. This step can take up to 30 days to complete. If the appeal qualifies as expedited, it will be reviewed within 48 hours.

Quick link: Become A Provider

Requirements: Tax ID Number

Notes: Contracting and credentialing are two unique processes at Sunshine Health. Contracting is the process of negotiating reimbursement rates and executing an agreement at the tax ID level. Credentialing is for verifying that each practitioner or facility meets all the necessary requirements to provide services to our members.

Requirements: Provider Roster, Tax ID Number

Notes: Delegated enrollment requires approval from the Agency for Health Care Administration (AHCA). Sunshine Health cannot proceed with executing a Delegated Credentialing Agreement (DCA) until AHCA approval is obtained. Please note that the AHCA approval process may take more than 90 days to complete.

Requirements: Tax ID Number

Notes: Please allow up to 30 days to process your demographic update. A confirmation notice will be sent to the submitter's email address after the request has been processed.

Quick link: LOAP/Roster Template (xlsx)

Requirements: Billing NPI, LOAP/Roster, Rendering NPA, Tax ID Number

Notes

  • Sunshine Health processes provider enrollment requests in the order they are received (first-in, first-out). Please allow up to 60 days from the receipt of a complete and clean application for processing. Services shoud not be rendered until an enrollment confirmation notice has been issued by Sunshine Health.
  • To avoid delays and ensure uninterrupted access to care, we encourage timely roster submissions and proactive planning. Please note that status inquiries submitted via email before the 60-day service level agreement (SLA)  delay overall processing times for all providers.
  • A confirmation notice will be sent to the submitter's email address within 24 hours of receiving the enrollment request.

Quick link: Find Your Provider Engagement Account Manager (PEAM)

  • Community engagement inquiries
  • General health plan education/training
  • Escalate concerns that remain unresolved after working through the appropriate channels
  • New provider orientation
  • Other issue(s) not included on this page

Notes: Please reach out to your Provider Engagement Account Manager (PEAM) after you've followed the proper channels to resolve an issue. Your PEAM is here to assist you with any remaining outstanding issues and to help you navigate the health plan. When you contact your PEAM, please allow up to 3 business days for a response.