Chapter 1: Welcome to Sunshine Health

1 Table of Contents Sunshine Health MMA, SMI, LTC and CWSP Provider Manual 2021 Sunshine Health 2 Chapter 1: Welcome to Sunshine Health .. 9 Key Contacts and Important Phone Numbers .. 9 Medicaid in Florida .. 10 About Sunshine Health .. 12 Managed Medical Assistance (MMA) .. 12 Child Welfare Specialty Plan (CWSP) .. 12 Serious Mental Illness .. 13 Comprehensive (includes MMA and Long Term Care Services) .. 13 Guiding Principles .. 13 Informational Tools for Providers .. 15 Website .. 15 Secure Provider Portal .. 15 Member Benefits .. 16 Chapter 2: Member Eligibility .. 17 Eligibility Determination .. 17 MMA and CWSP .. 17 SMI .. 17 Comprehensive .. 17 Member ID Cards .. 18 Verifying Member Eligibility .. 19 Methods to Verify Eligibility .. 19 Preferred Method .. 19 Other Methods .. 19 Chapter 3: Credentialing and Recredentialing .. 20 Credentialing and Recredentialing Overview.

2 20 Credentialing Requirements for MMA and CWSP Practitioners and Providers .. 22 Requirements for Practitioners .. 22 Requirements for Providers .. 23 Credentialing Requirements for Behavioral Health Facilities .. 23 Credentialing Requirements for LTC Providers .. 24 Credentialing Committee .. 25 Recredentialing .. 26 Right to Review and Correct Information .. 26 Right to Appeal Adverse Credentialing Determinations .. 27 Chapter 4: Utilization Management and Prior Authorization .. 28 Utilization Management Program Overview .. 28 UM Contact Information .. 29 Clinical Practice Guidelines .. 29 Emergency Services .. 29 Sunshine Health MMA, SMI, LTC and CWSP Provider Manual 2021 Sunshine Health 3 Services Requiring Prior Authorization .. 30 MMA and CWSP Members .. 30 Comprehensive Members .. 30 Submitting Prior Authorization Requests .. 31 Timeliness of Decision .. 31 Non-Urgent Pre-Service Determination .. 31 Urgent or Expedited Pre-Service Determination.

3 32 Urgent Concurrent and Post-Stabilization Determination .. 32 Medical Necessity Review .. 32 Medical Necessity of Services Under CHCUP/EPSDT .. 33 Post-Service Decisions/Retrospective Review .. 33 Continuity of Care .. 34 Continuity of Care for New Members .. 34 Continuity of Care Following Provider Termination .. 35 Chapter 5: Provider Requirements for Pregnant Members and Newborns .. 35 Notice of Pregnancy .. 35 Prenatal Vitamins Benefit .. 36 Florida s Healthy Start Program .. 36 Medical Record Documentation Requirements for Pregnant Members .. 37 Pregnancy-Related Care by Maternity Providers .. 38 Hospital Service and Documentation Requirements for Newborns .. 38 Infant Care Service and Documentation Requirements .. 39 Chapter 6: Provider Requirements for Treating Children and Youth .. 40 EPSDT and CHCUP Programs .. 40 Vaccines for Children Program .. 41 Florida SHOTS .. 42 Nursing Facility Notification Requirements.

4 42 Chapter 7: Provider Requirements for CWSP Members .. 43 Partnership with Community-Based Care Integrated Health (CBCIH) .. 43 Child Welfare Specialty Provider Network .. 43 Authorized Callers .. 44 CBCIH Identification of Medical Consenters .. 44 Exceptions to Medical Consent for CWSP Members .. 44 Trauma-Informed Care .. 44 Behavioral Health Screening and Assessment .. 45 Comprehensive Behavioral Health Assessment .. 45 Medication Management for CWSP Members .. 45 Prescribing Psychotropic Medications for CWSP Members .. 45 Contraceptive Services .. 46 Sunshine Health MMA, SMI, LTC and CWSP Provider Manual 2021 Sunshine Health 4 Chapter 8: Member Complaints, Grievances and Appeals .. 47 Member Rights for Grievances and Appeals .. 47 Definitions of Complaints, Grievances and Appeals .. 47 Complaint .. 47 Grievance .. 48 Appeal .. 48 Filing Grievances and Appeals .. 48 Medicaid Fair Hearing .. 49 Trending of Complaints, Grievances and Appeals.

5 49 Chapter 9: Case Management .. 49 Case Management Program Overview .. 49 Integrated Medical and Behavioral Health Approach .. 50 Identification of Members for Case Management and Condition Management .. 51 Case Management Levels for Members .. 51 Tier 1 Complex Case Management .. 51 Tier 2 Emerging Complex Case Management .. 51 Tier 3 Chronic Condition Management .. 51 Tier 4 Health and Wellness Management .. 52 Case Management for Comprehensive Members .. 52 Condition-Specific Programs .. 53 Programs for Members .. 53 Member Incentive Program .. 54 Chapter 10: Quality Improvement Program .. 54 Quality Improvement Program Description .. 54 Quality Improvement Program Goal and Activities .. 55 Working with our Providers .. 56 Quality Improvement Committee and Sub- Committees .. 56 Quality Improvement Committee and Sub-Committees Overview .. 56 Quality Improvement Committee .. 56 Utilization Management Committee.

6 57 Credentialing Committee .. 57 Pharmacy and Therapeutics Committee .. 57 Peer Review Committee .. 58 Child Welfare Advisory Committee .. 58 Serious Mental Illness (SMI) Provider Advisory Committee .. 58 Provider Advisory Committee .. 58 Comprehensive Member Advisory Committee .. 59 Quality Improvement Activities .. 59 Monitoring Patient Safety/Quality of Care .. 59 Monitoring Provider Access and Availability .. 59 Monitoring Quality Outcomes .. 60 Quality Studies/Improvement Projects .. 62 Sunshine Health MMA, SMI, LTC and CWSP Provider Manual 2021 Sunshine Health 5 Fraud, Waste and Abuse .. 63 Special Investigations Unit .. 63 Office of Inspector General (OIG)/General Services Administration (GSA) Exclusion63 Provider Implementation of FWA Safeguards .. 64 False Claims Act .. 64 Healthcare Laws .. 64 Direct Reporting of Fraud, Waste and Abuse .. 65 Authority and Responsibility .. 65 Chapter 11: Provider Roles, Rights and Responsibilities.

7 66 Responsibilities of All Sunshine Health Practitioners .. 66 PCP Responsibilities and Covered Services .. 69 PCP Responsibilities for All Members .. 69 Covered PCP Services .. 69 Additional PCP Responsibilities for CWSP Members .. 70 Provider Programs and Accountabilities .. 73 PCPs and the Patient-Centered Medical Home (PCMH) .. 73 Coordination Between Physical and Behavioral Health .. 73 Identifying and Reporting Abuse or Neglect .. 74 Identifying and Reporting Critical Events .. 74 Telemedicine .. 75 Responsibilities of Network Specialists .. 76 Responsibilities of Network Hospitals .. 76 Responsibilities of Long Term Care Providers .. 77 General Requirements for All LTC Providers .. 77 Additional Responsibilities for Home and Community-Based Providers .. 77 Covered LTC Services .. 78 Chapter 12: Provider Administration .. 79 Provider Services and Supports .. 79 Appointment Wait Times .. 80 PCP, Specialist and Transportation Wait 81 Behavioral Health Practitioner Wait Times.

8 82 Provider Office Standards .. 83 Consumer Assistance Notice .. 83 Provider Training .. 83 Provider Training Overview .. 83 Initial Training .. 84 Required Training .. 84 Clinical Training .. 84 Behavioral Health Clinical Training .. 84 Training of Administers and Staff at Assisted Living Facilities .. 85 Provider Termination .. 85 Practitioner Addition to Existing Practice .. 85 Sunshine Health MMA, SMI, LTC and CWSP Provider Manual 2021 Sunshine Health 6 Marketing Activities by Providers .. 86 Provider Affiliation Announcements .. 87 Medical Record Documentation .. 87 Cultural Competency .. 88 Sunshine Health s Cultural Competency Plan and Evaluation .. 88 Provider Assistance with Cultural Competency Needs .. 89 PCP Administration .. 89 PCP Access and Availability .. 89 Member Panel Capacity for PCPs .. 90 Referrals by PCPs .. 90 Member Dismissal from a Panel .. 90 Unable-to-Locate Members .. 91 LTC Provider Administration.

9 92 LTC Provider Access and Availability .. 92 LTC Provider Accountability .. 92 LTC Referrals .. 92 LTC Provider Timeliness .. 93 Provider Coordination with Carve-out Public Health Services .. 93 Provider Complaints .. 95 Chapter 13: Member Administration .. 96 Member Rights .. 96 LTC Members have the right to: .. 97 Member Responsibilities .. 97 LTC Members have the responsibility to: .. 98 Advance Directives .. 98 Chapter 14: Pharmacy Program .. 99 Pharmacy Benefit .. 99 Pharmacy Benefit Manager .. 99 Preferred Drug List .. 100 Unapproved Use of Preferred Medications .. 100 Newly Approved Medications .. 100 DESI or IRS Drugs .. 101 Controlled Substances .. 101 Hemophilia Medications .. 101 Dispensing Limits .. 101 Over-the-Counter (OTC) Items .. 101 Prenatal Vitamins Benefit .. 101 Pharmacy and Therapeutics Committee Review of PDL .. 102 Prior Authorization Process for Medications .. 102 Prior Authorization Requests for Non-Specialty/Retail Medications.

10 102 Prior Authorization Requests for Specialty Medications .. 102 72-Hour Emergency Supply Policy .. 103 Sunshine Health MMA, SMI, LTC and CWSP Provider Manual 2021 Sunshine Health 7 Exclusions to the 72-Hour Emergency Supply .. 103 Psychotropic Medications .. 104 Chapter 15: Claims Coding and Billing .. 105 Risk Adjustment .. 105 Clinical Lab Improvement Act (CLIA) .. 105 EDI .. 105 Web .. 106 Paper Claims .. 106 Provider Billing Information .. 107 Required Provider Information .. 107 Changes in Billing Information .. 107 Billing Reminders .. 107 Coordination of Benefits .. 108 Processing by Other Insurance .. 108 Coordination of Benefits Processing .. 108 Claim Submission .. 109 Initial Claim Payment Process .. 109 Non- Nursing Facility and Non-Hospice Claims .. 109 Nursing Facility and Hospice Claims .. 109 Billing Forms .. 110 Billing the Member .. 110 Verification Procedures .. 110 Clean Claim vs. Unclean Claim.