Pre-Authorization Checklist
Case Management
All Sunshine Long-Term Care members assigned to Little Havana Activities & Nutrition Centers of Dade County, Inc. ("LHANC") are cased managed by Florida Care Management Services Agency, Inc. (“FCMSA”) -- a TPA-licensed vendor for Sunshine Health.
Prior Authorizations
Prior authorization is required for ALL services and products billed to LHANC for Long-Term Care eligible members. Claims billed without a prior authorization will be automatically denied by our claims system. Therefore, providers are advised to request and secure a prior authorization prior to rendering services to avoid claims reimbursement issues.
Authorization Requests
To request a prior authorization, please contact FCMSA:
Toll Free: 1 (877) 462-1200
Direct: (786) 477-4110
Eligibility Verification
Sunshine Health is responsible for providing LTC services once the Florida Department of Elderly Affairs determines an enrollee meets the medical requirements for nursing home level of care and the enrollee formally selects the Sunshine Health Comprehensive plan through AHCA’s Choice Counseling. Following that selection, the Department of Children and Family Services (DCF) determines if the member meets the financial criteria. Once AHCA receives confirmation of a member’s eligibility, AHCA notifies Sunshine Health of the member’s effective enrollment date. Coverage typically lasts for a year until DCF re-certifies the member.
During the annual recertification process, Comprehensive members may receive a 60-day extension of coverage and their benefit category is changed to “SIXT” on the secure provider portal of AHCA’s website.
Methods to Verify Eligibility
- Providers are asked to verify member eligibility by using the Sunshine Health's Secure Provider Portal. Using the portal, any registered provider is able to quickly check member eligibility by indicating the date of service, member name, and date of birth or the Medicaid ID number and date of birth.
- Providers may call Sunshine Health Provider Services at 1 (844) 477-8313. Providers are asked to supply the member’s name and date of birth or the member’s Medicaid ID number and date of birth.
Electronic Visit Verification (EVV)
Both LHANC and Sunshine Health collaborate with HHAeXchange (HHAX) and its electronic visit verification (EVV) technology to enhance member service and comply with the Agency for Health Care Administration's (AHCA) Statewide Medicaid Managed Care contract.
The HHAX portal remains LHANC’s and Sunshine Health’s method for communicating authorization information and billing to providers.
Effective January 30, 2025: LHANC and Sunshine Health will no longer accept EVV claims that have not been electronically confirmed or missing the appropriate visit exception reasons. We encourage providers to reduce and eliminate EVV exceptions — including manually altered visit times — to avoid any reimbursement delays.
To guarantee real-time EVV data collection, all visit files from providers using a third-party Electronic Data Interchange (EDI) vendor must be sent to HHAeXchange at least every two weeks.
Florida Providers NPI Data Changes
Florida has changed how it accepts electronic claims/encounters: Billing provider information must exactly match the National Provider Identifier (NPI) that AHCA has on file or the encounters will be denied. Providers must ensure they are validating their agency’s data and address on the Provider Master List (PML). Any changes made to the PML must be communicated to LHANC so health can update agency records.
Sunshine Health put together a tip sheet to help providers navigate these changes: