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Stay Connected on the Go! Download our Health Insurance Portal mobile app to search for care, view benefits and access your Member ID card. LEARN MORE AND DOWNLOAD THE APP

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

This guide is designed to help providers find the right team and resources to help resolve their issues.

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For Fastest Service: Use the 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. The portal allows you to:

  • Check member eligibility and benefits
  • View and track claim status
  • Submit and check the status of prior authorization requests
  • 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, contacting the appropriate department is the best approach. To help us assist you, please have the following information ready when you contact us:

  • Provider's Taxpayer Identification Number (TIN)
  • Provider's National Provider Identifier (NPI)
  • Member's ID Number and date of birth
  • Claim Number (for claim-specific inquiries)
  • Date(s) of Service
  • Authorization Number (for authorization-specific inquiries)
  • Practitioner Name and individual NPI (for credentialing-specific inquiries)

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Contact the Right Department

This guide can help providers avoid delays and ensure your questions are addressed by the correct team. Sending an inquiry to the wrong department, or sending an email to multiple inboxes, could delay Sunshine Health’s ability to provide a timely response.

Select the subject(s) you need help with to identify the best contact and resources to help answer your questions and resolve your issues.

Quick links

Required Information

  • TIN
  • Billing NPI
  • Date(s) of Service
  • Servicing Practitioner’s Full Name and NPI
  • Medical Records (if applicable)
  • Previous Ticket Number(s) [if applicable]

Provider Services

Options

  • General claim inquiries
  • Check the status of a claim

Submit a claim reconsideration, correct, or VOID a claim

A request for reconsideration/claim dispute should be used when a provider disagrees with the original claim outcome, such as payment amount or denial reason. The provider must resubmit additional information for review.

Providers are encouraged to follow the claims Reconsiderations and Disputes procedures outlined in the Provider Manual (PDF) when submitting requests.

All requests for reconsiderations/claim disputes must be received within 90 days from the date of the original explanation of payment or denial.

Reconsiderations can be submitted via:

An appeal is a request for a review of an action, which may include:

  • Denial, reduction, suspension, or termination of a service already authorized
  • Denial of all or part of the payment for a service

Appeals Guide: Medicaid Member and Provider Appeals Processes

Mail 1st level (Reconsideration) and 2nd level (Dispute) appeals to:
Sunshine Health
Attn: Adjustments/Reconsiderations/Disputes
P.O. Box 3070
Farmington, MO 63640-3823

(Applicable to claims payment and Medical Necessity appeals)

If, after submitting an appeal you believe further review of your claim is warranted, please utilize our Claim Concerns Form.

  • Reconsideration is the first step a provider should take to appeal the plan’s original medical necessity denial. This process allows providers to request an informal review and submit supporting documentation for consideration. This initial step provides a quick review that can take up to 30 days to complete.
  • A dispute is the secondary step a provider should take if the provider is not satisfied with the plan’s reconsideration determination. This provides a secondary review of the documents submitted and a more advanced review. This step can take up to 60 days to complete.
  • An appeal is a formal, structured process to challenge a medical necessity denial, or  unfavorable decision after a claim has been fully adjudicated, reconsidered, and/or disputed. Appeals usually require supporting documentation, medical records, and written arguments. This is subject to strict timelines and regulations. This step can take up to 60 days to complete.

Providers should follow the appeals process as outlined in the Provider Manual (PDF) when submitting requests. If, after following these steps, further review is required, please utilize our Claim Concerns Form to resolve the issue. The review process can take up to 30 business days to complete. All claim reviews are subject to timely filing restrictions as detailed in our provider manuals and contractual agreements.

Quick Link: Become A Provider

Required Information: Taxpayer Identification Number (TIN)

Provider Resources

Change of Ownership (CHOW) Form

To update Sunshine Health about a change in ownership, or new ownership developments for the provider groups, individuals, and/or facilities visit: Change of Ownership (CHOW)

Notes: Contracting and credentialing are two different processes at Sunshine Health. Contracting is the process of negotiating reimbursement rates and executing an Agreement at the TIN level. Credentialing is the process for verifying that each practitioner or facility that is affiliated to an executed Agreement meets all applicable qualifications and requirements to deliver services to our members

Quick Link: Delegated Credentialing Form

Required Information

  • Delegated roster (providers may submit their own spreadsheet if the roster includes all the required fields per the DCA)
  • Billing Taxpayer Identification Number (TIN)
  • Billing Type 2 National Provider Identifier (NPI) or Type 1 NPI

Provider Resources

Note: Becoming delegated for credentialing requires approval from the Agency for Health Care Administration (AHCA) Entities are not considered delegated for credentialing until AHCA approval is obtained. Please note that the AHCA approval process may take more than 90 days to complete.

Quick Links

Required Information

Provider Resources: Submit a request to update provider demographics: Provider Demographics Form

Note: 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 Links

Required Information

Credentialing Triage: Add provider to an existing contract: Provider Enrollment Requests

Verification

To verify whether a practitioner is enrolled, use our Find a Provider tools:

Provider Resources

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 should 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 Links

Provider Resources

Provider Engagement Account Managers (PEAMs) can help providers with:

  • Community engagement inquiries
  • General health plan education/training
  • Escalate concerns that remain unresolved after working through the appropriate channels
  • New provider orientation
  • Other issues not addressed by this page

Use the Find Your Account Manager Tool to find your assigned PEAM.

Note: To resolve any issues, please go through the proper channels first before reaching out to your PEAM. Your account manager will assist you with any remaining issues and help you navigate the health plan’s processes.