Thank you for caring for our members by utilizing Sunshine Health programs and resources to help mothers deliver healthy babies. Over the past year, your participation helped ensure healthy outcomes for mothers and newborns.
To continue supporting our shared vision of improving birth outcomes in Florida, we are pleased to announce we are continuing our Birth Outcomes Provider Incentive program. The program’s two incentives are tied to Notification of Pregnancy (NOP) forms and hydroxyprogesterone caproate injections. Both incentives are paid monthly.
$50 for NOP forms submitted through our Secure Provider Portal within 30 days of the first prenatal visit.
To provide the best care and support for our members, it is critical that we receive an NOP form for every pregnant member immediately after she leaves your office. The sooner we learn our members are expecting, the sooner we can reach out to them with support and services designed to lead to healthy pregnancies and deliveries. Providers must submit the NOP through the Secure Provider Portal to be eligible for the incentive payment. For more information, please see the enclosed Frequently Asked Questions.
$75 for first dose of hydroxyprogesterone caproate when clinically appropriate.
If your Sunshine Health patient is at risk for preterm labor, hydroxyprogesterone caproate might be the right course of therapy. Studies show that compliance with an entire course of therapy can decrease preterm birth by 34%. Hydroxyprogesterone caproate can be administered in your office or through Optum’s Makena® Administration Nursing and Care Management Services in your patient’s home. For more information, please see the enclosed Frequently Asked Questions.
To supplement care provided to expectant mothers and children, please share this with your office staff. And when appropriate, talk about these important resources with your Sunshine Health patients so they can take an active role in their health, especially during pregnancy.
If you have questions, please call Provider Services at 1-844-477-8313 from Monday–Friday, 8 a.m. to 8 p.m. Eastern.
Hydroxyprogesterone Caproate® and Notification of Pregnancy (NOP) Frequently Asked Questions
Which providers are eligible for the hydroxyprogesterone caproate and Notification of Pregnancy (NOP) incentives?
Any participating Sunshine Health maternity provider is eligible to receive the incentives.
What products are included in these incentives?
Sunshine Health’s Medicaid, Serious Mental Illness (SMI) Specialty Plan, Child Welfare Specialty Plan and Children’s Medical Services (CMS) Health Plan products are included.
How do providers submit an NOP or notification that hydroxyprogesterone caproate has been administered to be considered for payment?
Any NOP that is received through the Sunshine Health Secure Provider Portal between Jan. 1, 2022, and Dec. 1, 2022, will be considered for payment. Any claim for the first dose of hydroxyprogesterone caproate with a date of service between Jan. 1, 2022, and Dec. 1, 2022, will be considered for payment. The member must be enrolled with Sunshine Health on the date of service for payment to be made.
Are any members excluded?
Yes. Sunshine Health is not including any member whose Medicaid category is SSI with Medicare. This exclusion is because Medicare is the primary insurance for these members.
Is there a number of members a maternity provider must see to qualify for this incentive program?
No. Any of our participating maternity providers are eligible to participate. If there is one member for whom an NOP is completed or the first dose of hydroxyprogesterone caproate is administered, the maternity provider can participate.
Are there specific codes that must be used for the first dose of hydroxyprogesterone caproate?
Yes. A medical or pharmacy claim must be submitted to Sunshine Health with one of the following codes:
- If billing to Sunshine Health through the medical benefits, use HCPCS codes J1726 or J1729.
- If billing through Sunshine Health’s pharmacy benefits, use the following NDCs: 00517176701, 00517179101, 55150030901, 66993003883, 67457096701, 69238179701, 71225010501, 64011030103.
How does Sunshine Health determine which maternity provider is paid?
For the NOP, payment is made to the maternity provider who is seeing the member for that pregnancy. We realize that our members may switch maternity providers during pregnancy. In these cases, payment can be made to another maternity provider, when they submit an NOP, after their first prenatal visit with that member. For hydroxyprogesterone caproate payment, the maternity provider who is listed as the prescriber for the first dose of hydroxyprogesterone caproate based on the fill date for the first dose will receive the incentive.
Do providers need to take any additional steps to get paid?
Yes. It is important that Sunshine Health has an up-to-date W9 form as payments will be made by check. To ensure checks are sent to the correct address, a current W9 must be emailed to Sunshine Health at Sunshine_Accounts_PA@centene.com.
How will providers be paid?
On a monthly basis, Sunshine Health will determine if a maternity provider has provided services that meet the criteria for these incentives. Providers will be sent a separate monthly check for incentives earned. The memo line in the check will note “maternity incentive.” Providers can find details on members who qualified and for whom the payment is made through our Secure Provider Portal. Click Provider Analytics, then Reports.
When will providers be paid?
On a monthly basis, Sunshine Health will identify which members had qualifying services for the previous month. Payment will be made for each qualifying activity for that previous month. The payment will be made the month after the NOP or claim for hydroxyprogesterone caproate has been submitted.
How can providers refer a member to Optum to administer hydroxyprogesterone caproate in a member’s home?
Optum is a participating Sunshine Health provider that offers support for pregnant women in their home. If you have a patient that could benefit from hydroxyprogesterone caproate being administered in her home, you can send a prescription to Optum by fax at 1-866-252-4293 or 1-866-731-9011; email the signed and scanned prescription to OBHintake@optum.com, or call 1-800-950-3963.
Are there other supports for at-risk pregnant Sunshine Health members?
Yes. Optum offers other in-home support for at risk pregnant members. Programs include gestational/pre- gestational diabetes, gestational hypertension, preeclampsia, preterm labor, and nausea and vomiting during pregnancy. You can refer members to Optum as noted above.
Sunshine Health also has our Start Smart for Your Baby maternity program. This program provides individualized, comprehensive care for expectant mothers and newborns to ensure healthy pregnancies and deliveries. The program is offered at no cost to members. Our care management team provides support for maternity education, coordinates care with maternity providers and other specialists, and helps connect the member to community resources, such as WIC, Healthy Start, SNAP and other services that address social determinates of health. Encourage your Sunshine Health patients to enroll by calling Member Services at 1-866-796-0530 (TTY 1-800-955-8770).
How can providers refer Sunshine Health members to the Start Smart for Your Baby maternity program?
A referral can be made through our Secure Provider Portal. It will be sent to our case management team so they can reach out to the member. You can also call Provider Services at 1-844-477-8313 and select the prompt for case management.
How do I register for the Sunshine Health Secure Provider Portal?
Go to the Secure Provider Portal and create an account.
What information is in the Secure Provider Portal?
Inside the Secure Provider Portal, you can access tools and functions to help you verify coverage eligibility, track your incentive payments and view customized Provider Analytic reports.
Is there information that must be completed in the NOP?
Yes. There are required fields in the NOP. These are essential so that Sunshine Health can correctly identify you as the maternity provider submitting the NOP, the correct member and essential information about the member’s pregnancy. Details about the member’s current and past pregnancies are used to help Sunshine Health identify those who may be at risk for a poor birth outcome. See the Notification of Pregnancy Form and the fields noted with an * as required. In order to receive the incentive, the NOP must be completed through the Secure Provider Portal.
How do providers submit a NOP through the Secure Provider Portal?
There are 3 easy steps to submit an NOP:
- Open patient’s chart in Secure Provider Portal, and click Assessments
- Click Fill Out Now
- Complete all fields, then click Submit at the end.
What are the clinical guidelines for hydroxyprogesterone caproate?
Sunshine Health follows the Agency for Health Care Administration (AHCA) guidelines for the criteria on when hydroxyprogesterone caproate should be administered. Those are:
Hydroxyprogesterone caproate should be administered when medically necessary due to reduce the risk of preterm birth in women with a history of preterm birth.
- Must be a singleton pregnancy at 16 to 37 weeks gestation
- Patient must be at least 16 years old
- Hydroxyprogesterone caproate is not intended for women with multiple gestations or other risk
factors for preterm birth
Hydroxyprogesterone caproate is designed to be administered once weekly, with treatment beginning between 16 weeks and 20 weeks, 6 days of gestation. Treatment can continue weekly through week 37 of gestation. Dosage forms:
- Available as hydroxyprogesterone caproate auto-injector 275mg administered subcutaneously.
- Available as hydroxyprogesterone caproate (single or multi-dose vials) 250mg administered intramuscularly.
Hydroxyprogesterone caproate can be administered by the maternity provider or prescribed by the maternity provider and administered by a nurse in a patient’s home or at an appropriate location convenient for the patient.