The transition to Sunshine and it’s Growing pains
Orializ Gonzalez
Description
Collection
Title:
The transition to Sunshine and it’s Growing pains
Creator:
Orializ Gonzalez
Date:
2/23/2022
Text:
Dear Colleagues,
The Florida Association of Orthotists and Prosthetists (FAOP) is aware that members and non-members alike are experiencing Prior Authorization (PA) and claims payment issues with Sunshine Health Plan and their Children’s Medical Services Health Plan. In response, the FAOP board has been communicating with Sunshine’s leadership to establish a process to work collaboratively while they resolve their internal issues.
As you may know, Sunshine recently announced it is waiving DME PAs for Sunshine Medicaid, Sunshine specialty, and Children’s Medical Services claims with a total value of over $5,000 through March 31, 2022. Also, PAs are waived for Long Term Care member claims with a total value under $10,000 through March 31, 2022. Be aware that although these PAs are waived, claims may be subject to retrospective review for medical necessity and correct coding/billing, so it is strongly recommended that you document and maintain notes demonstrating necessity as usual.
For claims that do not fall within the PA waiver criteria, please only submit the PA request once. Multiple requests for the same care are currently creating a backlog especially if submitted via fax. If you have submitted a PA because your claim is not waived per the Sunshine PA notification and have not received a response within a business week, please forward your request information to the FAOP email and we will assist.
Finally, please contact us if you are currently experiencing significant account receivable (AR) issues with Sunshine or are experiencing a consistent denial for a claim that should be approved. The FAOP will facilitate one-on-one scheduled calls with Sunshine executives to promptly address any significant AR situations and will also work directly with Sunshine to resolve any systemic denials that are received and that you believe should be approved.
The FAOP is here to assist you in providing appropriate care to your patients as Sunshine resolves their IT issues. Please feel free to notify us of any other issues you are currently experiencing with Sunshine that are not addressed in this communication for us to engage on.
Please understand that the FAOP is a membership organization and that assistance with Sunshine claims is a service provided exclusively to members of the FAOP. This is one small example of how the FAOP works with its members to improve the delivery of care in Florida, and demonstrates we are consistently working together with professionals in the State. For this reason, we strongly encourage you to become a member of the FAOP so that services such as these can be extended to a majority of individuals affected. There is power in numbers and demonstrating a unified purpose across Florida will demonstrate that issues are far reaching and affecting a large number of individual practitioners, facilities and patients alike.
Thank you for all you do for patients in Florida.
Orializ González, MS, LPO, CPO
The FAOP Board of Directors
<URL Redacted>
The Florida Association of Orthotists and Prosthetists (FAOP) is aware that members and non-members alike are experiencing Prior Authorization (PA) and claims payment issues with Sunshine Health Plan and their Children’s Medical Services Health Plan. In response, the FAOP board has been communicating with Sunshine’s leadership to establish a process to work collaboratively while they resolve their internal issues.
As you may know, Sunshine recently announced it is waiving DME PAs for Sunshine Medicaid, Sunshine specialty, and Children’s Medical Services claims with a total value of over $5,000 through March 31, 2022. Also, PAs are waived for Long Term Care member claims with a total value under $10,000 through March 31, 2022. Be aware that although these PAs are waived, claims may be subject to retrospective review for medical necessity and correct coding/billing, so it is strongly recommended that you document and maintain notes demonstrating necessity as usual.
For claims that do not fall within the PA waiver criteria, please only submit the PA request once. Multiple requests for the same care are currently creating a backlog especially if submitted via fax. If you have submitted a PA because your claim is not waived per the Sunshine PA notification and have not received a response within a business week, please forward your request information to the FAOP email and we will assist.
Finally, please contact us if you are currently experiencing significant account receivable (AR) issues with Sunshine or are experiencing a consistent denial for a claim that should be approved. The FAOP will facilitate one-on-one scheduled calls with Sunshine executives to promptly address any significant AR situations and will also work directly with Sunshine to resolve any systemic denials that are received and that you believe should be approved.
The FAOP is here to assist you in providing appropriate care to your patients as Sunshine resolves their IT issues. Please feel free to notify us of any other issues you are currently experiencing with Sunshine that are not addressed in this communication for us to engage on.
Please understand that the FAOP is a membership organization and that assistance with Sunshine claims is a service provided exclusively to members of the FAOP. This is one small example of how the FAOP works with its members to improve the delivery of care in Florida, and demonstrates we are consistently working together with professionals in the State. For this reason, we strongly encourage you to become a member of the FAOP so that services such as these can be extended to a majority of individuals affected. There is power in numbers and demonstrating a unified purpose across Florida will demonstrate that issues are far reaching and affecting a large number of individual practitioners, facilities and patients alike.
Thank you for all you do for patients in Florida.
Orializ González, MS, LPO, CPO
The FAOP Board of Directors
<URL Redacted>
Citation
Orializ Gonzalez, “The transition to Sunshine and it’s Growing pains,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/255774.
