Social Determinants of Health (SDOH) Incentives

Social Determinant of Health (SDOH) are nonmedical factors that can influence health outcomes such as economic, environmental and social conditions. Sunshine Health offers incentives to providers who submit detailed claims or encounters using SDOH ICD-10-CM Z Codes.

ICD-10-CM-Z Codes

Z Codes represent factors that influence health status and any contact with health services that may be recorded as diagnoses. Codes Z-55 through Z-65 identify non-medical factors that may influence a member’s health. To learn more about benefits and barriers to utilizing Z Codes, we encourage providers to reference this Quick Guide to SDOH ICD-10 Codes (PDF).

Incentives

Sunshine Health offering incentive payments to all providers who bill for an assessment. The results can be positive or negative, but positive results should include procedures codes for interventions. It’s important that members are regularly screened. The incentive will be reimbursed two times per year as follows.

Incentive: These payments are made in addition to the compensation arrangement set forth in your participation agreement in our provider network.

• $20 for reporting a positive SDOH screening and referral along with appropriate Z Code for pregnant enrollees
  • Diagnosis code(s) on the claim should indicate member is pregnant
  • Providers should include the “TH” modifier when billing, which is required when submitting claims for pregnant members
  • Providers should also file a Notice of Pregnancy (NOP) whenever they diagnose a member as pregnant via the member’s account in the Secure Provider Portal
  • Referrals to Case Management can also be made through the member’s account in the Secure Provider Portal
    
• $10 Provider incentive for reporting a positive SDOH screening and referral along with the appropriate Z Codes for enrollees
• $10 Provider incentive for reporting a negative SDOH screening along with the appropriate Z Codes for enrollees
• Claims will be adjudicated and paid as they are billed
  

Providers should report these screenings by billing the appropriate CPT codes below to indicate food, housing and/or transportation insecurities. The best practice is for providers to ask the member if they have recently received a screening. Providers should use one of the two G codes below to indicate the screening was performed and to indicate the outcome:

• Screening Performed and Negative: G9920
• Screening Performed and Positive and Provision of Recommendations: G9919
  

Code Intervention Categories

This list is subject to revisions and additions to improve alignment with SDOH data elements. The approved CPT codes to be used for billing are:

• Food Insecurities: 96160
• Housing Instability: 96156
• Transportation Insecurity: 96161

Note: Providers must have an updated W-9 tax form on file with the health plan to ensure no disruptions in payment. To update your W-9, utilize the Provider Demographics Updates tool.

Questions?

Contact your Sunshine Health Provider Engagement Account Manager (PEAM) or call Provider Services at 1-844-477-8313.