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WellCare Integration

Valued providers for Sunshine Health and WellCare of Florida:

Centene and WellCare/Staywell Health Plan brought our health plans together to better serve our members, providers, partners and communities on October 1, 2021. Stay tuned to this page for updates. In addition, we will continue hosting virtual Provider Town Halls to answer your questions.

If you’ve recently attended any of our town halls, please kindly take a moment to complete this survey. We’d really like to hear your feedback.  

Centene Corporation finalized its acquisition of WellCare Health Plans, Inc. on January 23, 2020. Centene is the parent company of Sunshine Health; WellCare is the parent company of WellCare of Florida and Staywell Health Plan.

 

As part of our ongoing integration efforts to combine the best of both Sunshine Health and WellCare health plans, we have reviewed policies and processes regarding prior authorization. The goal of our combined company is to ensure the highest quality care for our members in partnership with our providers.

The notification is to advise you that at this time, the plans are aligned on which services do and do not require a prior authorization and there are no significant changes.

The information below applies to our Medicaid (Sunshine Health and Staywell Medicaid and Long Term Care), Child Welfare Specialty Plan, Serious Mental Illness Plan and Children’s Medical Services Health Plan products. Any deviations by product are noted below.

The health plan suggests utilizing the prior authorization check tool on our website to verify if an authorization is required:

The services listed below require a prior authorization:

  • Inpatient facility admissions,  inpatient hospice, detox, SNF and Other Post-Acute Care Services
  • SIPP (Statewide Inpatient Psychiatric Program)
  • Inpatient psychiatric admissions
  • Air transport
  • NEMT with non-participating providers
  • Hospice care
  • DME and O&P
  • NEMT over 100 miles
  • Inpatient detox admissions
  • Genetic testing
  • Non-medical NEMT transport for CW members
  • Ambulatory detox
  • Home health and home infusion
  • Pain management programs and services
  • Select Behavioral Health Community - based services
  • Private duty nursing
  • Potentially cosmetic surgery
  • Partial hospitalization
  • OT, PT, ST
  • Quantitative drug testing
  • Hearing aids
  • Procedures done in outpatient setting, ambulatory surgical center or office
  • Implantable devices (cochlear implants)
  • Family training and counseling for child development
  • Multi-systemic therapy
  • Sleep studies performed in the home
  • Infant mental health testing
  • Shingles vaccine
  • High tech radiology
  • Intensive outpatient therapy Mental Health
  • Pneumonia vaccine
  • Injectable drugs and drugs given by an MD in office setting, IV infusion
  • Intensive Outpatient Program  for Substance Use Disorder
  • Therapeutic abortions
  • Ambulatory surgery
  • Transplants
  • Dental or oral surgical procedures requiring general anesthesia
  • Behavioral Health Residential outpatient treatment
  • Applied Behavior Analysis (ABA) – Title 21
  • Bariatric surgery
  • Investigational/experimental

The services listed below do not require prior authorization:

  • Mobile crisis assessment and intervention
  • Behavioral health assessment services
  • Medical foster care
  • Early Intervention Services (EIS)

For questions or concerns, please contact your Provider Relations representative. You can also call Sunshine Health Provider Services at 1-844-477-8313.

 

Centene’s acquisition of WellCare's Medicaid products, including Staywell Health Plan, will be complete Oct. 1, 2021. Sunshine Health will also operate the Department of Health’s Children's Medical Services Health Plan beginning Oct. 1, 2021. WellCare Medicare products, claims and correspondence procedures are not changing at this time. We value your partnership and want to help ensure proper claim submission to each plan based on the dates of service.

 

Sunshine Health offers many convenient and secure tools to assist providers.

Where can providers access the secure Sunshine Health Secure Provider Portal?

Providers can visit the Sunshine Health Secure Provider Portal to review member benefit information, submit authorizations and claims as well as file claims disputes.

Where can providers locate and complete trainings (including required New Provider Orientation and Compliance trainings)?

  • Options for initial and ongoing training include live sessions, instructor-led sessions, specialized webinars, and/or self-paced trainings through Relias Learning, an online learning management system.
  • Please visit Provider Training to get started. Providers are encouraged to review the Provider Manual for specific plan-required trainings at Manuals, Forms and Resources.

Are office managers/administrators able to attend trainings on behalf of the provider?

Yes, any group/office staff members can attend the training.

Where can providers reference Sunshine Health’s claim submission and EDI guidelines?

Guidelines for Proper Claims Submissions

Can providers submit corrected claims via the Sunshine Health Secure Provider Portal?

Yes. Providers can also submit a corrected claim through any of the acceptable EDI clearinghouses.

Where can providers find Sunshine Health’s clearinghouse partners?  

All clearinghouse partners currently active with Sunshine Health are listed under Electronic Transactions. Contact one of these trading partners to use our electronic transaction options.

Where should I go to update my PaySpan account?

  • Go to payspanhealth.com/nps and click User Login.
  • Once logged in, update the Payer IDs:
    • Sunshine Health is 68069
    • Ambetter is 68068
  • If needed, please update to the correct address. Then contact Sunshine Health at 1-844-877-8313 to update your address in our systems.
  • If you encounter any technical difficulties, please contact the PaySpan Provider Support team at 1-877-331-7154 or email providersupport@payspanhealth.com.
  • See PaySpan News for more information.

Where can providers access and review Sunshine Health’s clinical policies?

Clinical & Payment Policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or by payment rules.

Where can providers access prior authorization forms for pharmacy/medication requests?

We cover prescription medications and certain over-the-counter medications with a written order from a Sunshine Health provider. Visit Pharmacy to learn more.

 Where do I reach out with claim concerns/questions?

How can a provider locate their Provider Relations Representative’s name and contact information?

Use our Find My PR Rep tool.

What is the Continuity of Care (CoC) period?

  • Legacy Staywell members have 120 days after October 1, 2021, to continue seeing a Legacy Staywell provider who is non-participating with Sunshine Health.
  • Legacy CMS members have 120 days after October 1, 2021, to continue seeing a Legacy CMS provider who is non-participating with Sunshine Health.

Where can I locate information on Sunshine Health’s contracted vendors?

Vendors

If providers have questions or concerns regarding Sunshine Health’s contracted vendors, where should they send an inquiry?

Providers can email our Subcontractor Department at SH_VendorManagement@centene.com.

How do providers know which type of health plan members have?

  • Providers can submit authorizations, claims, file claims disputes as well as review member benefit information on our Sunshine Health Secure Provider Portal.
  • Providers can also view examples of member ID cards below.

Do providers need to submit dual members’ claims differently?

No, if the member presents with Wellcare Medicare and Sunshine Health Medicaid, providers will continue to submit the claim to Wellcare for processing for the Medicare claim, which initiates the spawn process. Sunshine Health Medicaid will then process the Medicaid “coordinated” claim. Providers will continue to receive two (2) explanation of payments (EOPs).

Where should providers go to obtain contract information regarding rates, covered services, contract notices, etc.?

Providers can send a secure email to our Contracting team at sunshinecontracting@centene.com. Please include the legal name, Tax ID and NPI and a member of our Contracting team will respond within 2-5 business days.

Which provider types need to submit claims through the HHA Exchange (EVV) Portal?

Private Duty Nursing, Personal Care, Home Health, Adult Companion Care, Adult Day Health Care, Assistive Care Services, Attendant Care, Companion Care, Homemaker, Intermittent and Skilled Nursing – LPN & RN and Respite Care (home)

Are providers required to obtain authorization for patients covered by an LTC plan?

Providers do not need to obtain authorizations for LTC covered services. Service authorizations are coordinated between the member and the member’s POA. LTC Case Managers submit authorization requests to our LTC Utilization Management team to review processes and initiate the service authorizations.

Where do providers locate the Medicaid outpatient prior authorization form for authorization requests?

Please visit Provider Resources and select “Medical Management” to view our Outpatient Authorization forms.

Are referrals required for members to see specialists?

PCPs should coordinate healthcare services and are encouraged to refer a member to the appropriate network provider when medically necessary care is needed that is beyond their scope. However, members may self-refer for all services, including referrals to specialists and behavioral health providers. PCPs and obstetricians/gynecologists are required to notify Sunshine Health promptly when providing prenatal care to a Sunshine Health or CMS member.

Are authorizations required for OT and ST re-evaluations?

Authorizations are not required for evaluations nor re-evaluations. Providers are always encouraged to visit our pre-authorization tool at:

Where do providers submit ABA service requests?

Applied Behavioral Analysis (ABA) services require prior authorization. All Medicaid ABA authorization requests should continue to go to EQHealth for CMS Title 19. ABA authorizations for CMS Title 21 members should be sent to the health plan for further processing.

Does the health plan require authorization for behavioral health T and H codes?

Behavioral Health Authorizations
Procedure Code  Prior Authorization Required 

H0038

Yes

H2014 BA

Yes

H2017

No

H2019 BA

No, but will be monitored by our Outpatient Outlier Program

H2020 BA

Yes

H2021 BA

Yes

T1017

No

Where do providers submit a request to add products to their current contract?

  • If the provider is a non-contracted provider interested in joining the network or adding products to their current contract, they can visit our Join the Network page and click on “Contract Request Form” to initiate this process.
  • In addition, providers can send a secure email to our Contracting team at sunshinecontracting@centene.com. Please include the legal name, Tax ID and NPI.

Where should I direct provider additions, demographic updates, terminations?

  • Adding groups or individual practitioners
    • A W-9 form, Practitioner Roster/LOAP with additions, as well as a Disclosure of Ownership form are required. Please submit all supporting documentation to practitioneradds@centene.com. Access a LOAP (roster) template on our Become A Provider page to utilize as a guide when submitting these types of requests. 
  • Demographic updates or changes
    • A contracted medical or behavioral health practice that would like to update or make any changes to their demographic information should direct their request to SunshineProviderRelations@sunshinehealth.com. Please include all detailed information to assist in making the appropriate changes. Please feel free to utilize the LOAP form located on our Become A Provider page when notifying us of these updates or changes.
    • Providers can also submit their request via the online Contact form.
  • Terminations 
    • Providers should refer to their Sunshine Health contracts for specific information about terminating their contracts with Sunshine Health. In general, though, providers are required to notify the health plan within 90 days of terminating a provider or providers from a group or contract. Providers who want to terminate an individual practitioner within a practice or group should, provide the termination information on office letterhead and include the practitioner’s name, tax identification number, NPI, termination date and membership transfer information, if applicable, and also email the request to SunshineProviderRelations@sunshinehealth.com and notify your Provider Relations Representative.

 

 

Sunshine Health and Staywell Health Plan have been working hard to make the integration of our health plans as seamless as possible for our members, your patients.

In late-July/August, Staywell, Sunshine Health and Children’s Medical Services Health Plan members received letters in the mail telling them of the integration, effective Oct. 1, 2021.

The important thing to know is that members do not need to take any action.

Please assure your Staywell patients they will keep the same great benefits they have now, plus get even more through Sunshine Health. In most cases, members will keep their same care manager, doctors and prescriptions.

On Oct. 1, 2021, the Staywell name will go away and your Staywell Medicaid patients will become Sunshine Health members. Children’s Medical Services (CMS) Health Plan’s name will remain the same, but will be operated by Sunshine Health with the same benefits and services for members.

Member ID Cards

In mid-September, Staywell and CMS members will receive new Member ID cards in the mail. Below is how the ID card will appear.

Questions?

Call Provider Services at 1-844-477-8313, Monday through Friday from 8 a.m. to 8 p.m. Eastern, or contact your Provider Relations Representative.

Sample Medicaid ID card front and back

Sample CMS Title 19 ID card front and back

Sample CMS Title 21 ID card front and back 

 

Sunshine Health is excited to announce that we are expanding the number of transportation service providers to better serve our members and get them to needed medical appointments.

Starting Feb. 1, 2021, new transportation vendors will be implemented for Sunshine Health and Staywell Health Plan, customized by health plan. Members have been notified of these changes. We also want you to be aware of these changes in case you get questions from members.

Through each of the vendors — LogistiCare, Alivi and Medical Transportation Management (MTM) — members can schedule rides on-demand or future rides with a standing order for recurring needs.

Here is a breakdown of services for each vendor:

  • Medicaid: LogistiCare will provide transportation services for members enrolled in Sunshine Health and Staywell Medicaid, Staywell's Serious Mental Illness (SMI) Speciality Plan and Sunshine Health's Child Welfare Specialty Plan.
  • Medicare: LogistiCare will provide transportation services for WellCare of Florida Medicare and Allwell Medicare members.
  • Long Term Care: Alivi will provide transportation services for Sunshine Health and Staywell Health Plan Long Term Care members.

Sunshine Health will continue to operate its Member Advocacy Escalations Team for problems or emergencies that members may experience with transportation needs. If you have complaints or unresolved problems about transportation issues, please call 1-866-796-0530, ext. 6037559. The team can help solve problems Monday through Friday between 8 a.m. and 8 p.m. Eastern. 

Important note: Medical Transportation Management (MTM) will continue to provide transportation services for Florida Department of Health’s Children’s Medical Services Health Plan (CMS) operated by WellCare.

 

Please join us for our Provider Town Halls

The webinars cover a variety of topics such as status updates on our integration and information that providers need to know for our specialty plans. Space is limited. Please register in advance. Town Halls are scheduled to be offered all year. To register for an upcoming Town Hall or watch a recording of a previous Town Hall, please visit our Provider Training web page.

We are excited to announce the integration of Sunshine Health and WellCare’s Provider Relations teams.

This means you will have one Provider Relations Representative to assist you in serving both Sunshine Health and WellCare of Florida members, including our Medicaid, Medicare and Ambetter members and our specialty health plan members in Sunshine Health’s Child Welfare Specialty Plan, Staywell’s Serious Mental Illness (SMI) Specialty Plan and the Florida Department of Health’s Children’s Medical Services Health Plan (CMS). This change will be effective Aug. 3, 2020.

We expect to fully integrate our two companies in the second half of 2021. We are taking this step now to provide you with more streamlined and efficient service.

We Need Your Feedback

Our goal is to build a best in class Provider Relations team to meet your needs. Your input and feedback is crucial. We will be seeking your opinions about what each of our organizations does best, as well as how we can improve.

When we fully integrate, we will unite all of our products under the Sunshine Health brand. We are committed to keeping you up to date on changes before we make them. Stay tuned to this webpage where you can find all the integration information in one place.

Follow Your Current Contract(s)

For now please continue to treat members from each health plan as you do under your current contract. Our operational systems for each health plan, including Claims and Provider Services, remain separate. If you have questions, your Provider Relations representative is available to help you, regardless of whether your question is about Sunshine Health or WellCare. In some cases, your representative may change. We’ll let you know in advance if that happens. You can also call our dedicated Provider Relations Number at 1-407-551-3200, option 2.

 

Sunshine Health offers dedicated Provider Relations Representatives located in offices across Florida. Find your dedicated representative

 

 

Where do I submit current claims and after October 1?

  • DOS or Discharge prior to Oct. 1 online: WellCare Provider Portal
  • DOS or Discharge prior to Oct. 1 paper: WellCare Health Plans, Attn: Claims Department, P.O. Box 31372, Tampa, FL 33631-3372
  • DOS or Discharge after Oct. 1 Online: Sunshine Health Secure Provider Portal 
  • DOS or Discharge after Oct. 1 paper: Sunshine Health, P.O. BOX 3070, Farmington, MO 63640-3823, ATTN: CLAIMS DEPARTMENT
  • DOS or Discharge prior to Oct. 1 EDI: WellCare Provider Overview & Resources
  • DOS or Discharge after Oct. 1 EDI: Sunshine Health EDI & Billing Overview

PLEASE NOTE: These specialty types would need to submit all claims through the HHAX portal:

Private Duty Nursing, Personal Care, Home Health, Adult Companion Care, Adult Day Health Care, Assistive Care Services, Attendant Care, Companion Care, Homemaker, Intermittent and Skilled Nursing – LPN & RN and Respite Care (home).

What provider types need to submit claims through the HHA Exchange portal?

Private Duty Nursing, Personal Care, Home Health, Adult Companion Care, Adult Day Health Care, Assistive Care Services, Attendant Care, Companion Care, Homemaker, Intermittent and Skilled Nursing – LPN & RN and Respite Care (home).

Where should claim related inquiries be sent prior to Oct. 1?

Staywell MMA, SMI, LTC and CMS claim related inquiries containing a date of service before Oct. 1, should be directed through the WellCare Provider Portal by visiting: provider.wellcare.com. Please include all necessary information as part of your appeal or dispute. If providers are not in agreement with the determination of a previously disputed claim issue, inquiries should be directed to our Operations Account Resolution (OAR) team at PSU_ProviderInquiries@wellcare.com.

Where should claim related inquiries be sent Oct. 1 forward?

Providers are encouraged to utilize the Sunshine Health Secure Provider Portal. If providers are not in agreement with the determination of a previously disputed claim issue, inquiries should be directed to SunshineProviderRelations@SunshineHealth.com. Projects prior to Integration on Oct. 1, 2021, will continue to be reviewed until completion of the project.

Are providers still able to submit claims through Availity?

  • Yes, providers can still utilize Availity to submit claims; however, if your specialty type falls under those listed above as required to submit to HHA Exchange, providers should contact the HHAX EDI team directly at EDISupport@hhaexchange.com in order to ensure the proper connection is set up for file imports and editing of visits.
  • For Technical issues, please report any difficulties to HHA Exchange and Sunshine Health.

Are providers required to obtain authorization for patients covered by LTC plan at this time?

Providers do not need obtain authorizations for LTC covered services. Service authorizations are coordinated between the member and the member’s POA. LTC Case Managers submit authorization requests to our LTC Utilization Management team to review process and initiate the service authorizations.

Are LTC members assigned a Case Manager?

When a member is enrolled in the LTC program, they are manually assigned a Case Manager based on the member’s demographics (e.g., Spanish-speaking), location, and needs (BH, medical complexity, etc.). LTC Case Managers submit authorization requests to our LTC UM Team who reviews, processes and initiates the service authorizations.   

Will providers receive new authorizations for those members transitioning to Sunshine Health?

Sunshine Health is currently working to transition previously authorized services under WellCare spanning through Oct.1, 2021, which will be viewable by visiting the Secure Provider Portal.

How do I submit authorization requests after Oct. 1, 2021?

Providers are encouraged to submit online via Sunshine Health’s Secure Provider Portal. To confirm if a service requires authorization, please visit our authorization look up tool.

How do I reach Case Management?

  • Call Provider Services at 1-844-477-8313. This resource is available to assist in initially answering questions, researching issues, and providing messages to our Case Managers or other departments dependent on the need.
  • Providers can also email inquiries to LTC_Authorization_Inquiry_Box@CENTENE.COM. When emailing the box, please include the member ID and provider Tax ID.

What is the timeframe for Case Management to return a call back?

Target timeframe is within one (1) business day of when message is received; however, this is also dependent on the complexity of the issue.

Will member ID numbers be changing for LTC members transitioning to Sunshine Health?

Staywell LTC members began receiving new member ID cards in September 2021. Members do not need to take any action. They automatically become Sunshine Health members Oct. 1, 2021.

When can providers expect to receive contract amendments with new contractual updates, such as rates and which Contract governs?

The majority of our contractual notices have been mailed. If you have not yet received communication from Contracting regarding your contract, please email the Contracting team at sunshinecontracting@centene.com. Please include your Tax ID and Name when reaching out.

Where do I start if I am interested in becoming part of the Integrated Sunshine Health network?

Providers who are not currently contracted can fill out the “Contract Request Form” to Join Our Network.

Will Sunshine Health be transitioning Staywell members to the HHA Exchange portal with updated authorizations to continue providing LTC services?

Staywell open authorizations will be transitioned to the HHA Exchange portal by Oct. 1, 2021.

Will the health plan increase LTC monthly rent for providers to keep up with the increases in labor and other expenses?

Any inquiries related to LTC rates will need to be directed to our Contracting team at sunshinecontracting@centene.com. Please include your Tax ID and Name when reaching out.

Are authorizations required for Assisted Living Facilities (ALF) services?

Prior to Oct. 1, ALF’s require authorization under Staywell MMA and do not require authorization under Sunshine Health. After Oct. 1, ALF’s will not require authorization.

Regarding provider trainings, are office managers/administrators able to attend trainings on behalf of the provider?

 Yes, any group/office staff members can attend the training.

 

How does this help my practice?

Your Provider Relations Representative will be specially trained to understand the nuances and needs of your practice. Having one rep will also streamline communications, helping us align accountability, eliminate duplications and provide a consistent message.

Will my rep change? When will I be told?

In some cases, your Provider Relations Representative may change – but in many cases you will simply keep one of your existing representatives. If you will have a new representative, we will let you know in advance.

How does this help/what changes for my patients?

The entire integration process should be seamless to your patients but they will benefit from the extra care and efficiency you receive through this streamlined process.

Will members have/need new ID cards?

For now, members will continue to use separate ID cards. We will let you know in advance when that changes.

Now that I have one Provider Relations Representative for both WellCare and Sunshine Health, can I also file claims in a single place? Can I verify membership in a single place?

Not yet. Please continue following the same claims, authorization and verification processes you have been using under your current contract(s). We will let you know when we expect those systems to be fully integrated.

Are member benefits also changing?

Member benefits are not changing. Please follow current processes until further notice.  

Will my WellCare members be eligible for Sunshine Health Provider Quality Incentives?

For now, incentive programs will remain separate. Please follow the current process until further notice.

What if I communicate with Sunshine Health through a vendor but directly work with WellCare?

If you work with a vendor for Sunshine Health, you will continue to work with that vendor.

Do I now accept both Sunshine and WellCare patients if previously I only accepted one or the other?

No, your contract(s) remain the same.

Why should I attend a Provider Town Hall if I already meet regularly with my Provider Relations Representative?

Integrating the Provider Relations team is one of the first steps toward fully integrating our companies in 2021. We want you to have input and stay informed every step of the way. At the Town Halls, you’ll have an opportunity to meet your Provider Relations Representative, hear from Subject Matter Experts and take part in a Q&A session. We’ll let you know if these will be in person or online.

Does this change to which specialists I can refer my patients?

Our provider networks are not yet combined. Please follow your contract(s) for now.

When can I expect outreach regarding my existing contract(s)? What if I am contracted with Sunshine Health or WellCare and not both Health Plans?

Providers participating only with Sunshine Health will maintain that agreement and Staywell members will become Sunshine Health members in October 2021. Providers in both networks will receive communications clarifying which contracts will govern by product no later than July 1, 2021.