Billing & Reimbursement

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Use Sunshine Health

Why this matters

Sunshine Health portal work is easier to manage when eligibility findings, authorization status, claim follow-up, denial notes, and documentation ownership stay connected to the admission.

For treatment centers

Payer portals answer part of the workflow

The Sunshine Health portal may show eligibility, authorization status, claims, or messages from the payer. helps your team keep those findings connected to the admission, documentation, follow-up, and billing work around them.

Where helps

If your facility uses, VOB details, authorization status, payer routing, claim follow-up, denial notes, and documentation ownership can travel with the record instead of living across screenshots, spreadsheets, and inboxes.

What stays with the payer

Sunshine Health still controls portal access, coverage rules, authorization decisions, and payment decisions.

Portal at a glance

Provider guide for Sunshine Health Florida Medicaid MCO — credentialing, prior authorization, VOB, and behavioral health billing for Florida treatment centers.

Provider portal: https://sunshinehealth.com/providers
Insurance profile: View Sunshine Health profile →
Also known as: Centene Corporation
Parent company: Centene Corporation
Credentialing context: CAQH ProView plus Florida Medicaid enrollment (FMMIS) · 90-120 days
Operating states: FL

Daily portal workflows for treatment centers

Eligibility and VOB

Start with active eligibility, network status, cost-share, and whether the levels of care listed on the Sunshine Health profile are covered for the member: Medically Managed Detoxification · Residential Treatment (via FL 1115 SUD waiver) · Partial Hospitalization (PHP) · Intensive Outpatient (IOP) · Outpatient Treatment · Crisis Stabilization · Medication-Assisted Treatment (MAT) · Peer Support and Recovery Services.

Prior authorization

Use the profile criteria as the intake checklist before submitting an authorization request: Florida Medicaid Clinical Coverage Policies · ASAM Criteria (for SUD level of care determinations) · Florida Medicaid mental health criteria. Keep the clinical packet aligned with the portal's required fields.

Claim status and follow-up

After claim submission, use the portal to tie each follow-up back to the member eligibility response, authorization record, rendering or facility identifiers, and the payer routing confirmed during VOB.

Credentialing updates

Keep portal access aligned with credentialing context from the profile: CAQH ProView plus Florida Medicaid enrollment (FMMIS) · 90-120 days. New locations, tax IDs, and roster changes should not wait until a claim denies.

What to verify before admission

Confirm active coverage, network status, plan type, member responsibility, and the specific payer route attached to the member's plan.
Match the requested level of care against the profile's covered levels of care: Medically Managed Detoxification · Residential Treatment (via FL 1115 SUD waiver) · Partial Hospitalization (PHP) · Intensive Outpatient (IOP) · Outpatient Treatment · Crisis Stabilization · Medication-Assisted Treatment (MAT) · Peer Support and Recovery Services.
Prepare clinical documentation against the listed medical necessity criteria: Florida Medicaid Clinical Coverage Policies · ASAM Criteria (for SUD level of care determinations) · Florida Medicaid mental health criteria.
Check whether the member's state, product, or network arrangement changes portal access, payer routing, or authorization requirements.
Use the Sunshine Health insurance profile as the source page for credentialing, coverage, and payer-specific operating context.

Authorization and documentation notes

Treat the portal workflow as an admission-control checkpoint: the eligibility response, authorization request, clinical packet, and claim setup should all tell the same story before the first billed date of service.

For Sunshine Health, the profile lists medical necessity criteria that should shape the clinical packet: Florida Medicaid Clinical Coverage Policies · ASAM Criteria (for SUD level of care determinations) · Florida Medicaid mental health criteria. Build the request around those criteria instead of relying on a generic treatment summary.

Credentialing context from the profile is also operational context for the portal: CAQH ProView plus Florida Medicaid enrollment (FMMIS) · 90-120 days. Keep provider, facility, location, and tax ID records synchronized before claims go out.

Profile FAQs to keep nearby

What is the history of Sunshine Health in Florida?

Sunshine Health is Centene Corporation's Florida Medicaid managed care brand, formed following Centene's 2020 acquisition of WellCare Health Plans. Before the acquisition, WellCare of Florida and Centene's existing Florida Medicaid operations were consolidated under the Sunshine Health brand. Prior to this consolidation, Sunshine Health had operated independently as a Florida Medicaid MCO before being acquired by Centene. As a result, some providers may have legacy familiarity with WellCare of Florida or the original Sunshine Health — the current Sunshine Health is the successor entity to both, operating under Centene ownership as Florida's Medicaid managed care participant with one of the largest Medicaid enrollments in the state.

Does Sunshine Health cover residential SUD treatment in Florida?

Residential SUD treatment coverage through Sunshine Health depends on Florida's Medicaid program and its Section 1115 SUD waiver authority. Florida has pursued 1115 SUD waiver amendments to expand Medicaid coverage for residential SUD services, including for facilities classified as institutions for mental diseases (IMDs) with more than 16 beds. The specific facility certification requirements, length-of-stay limits, and authorization rules under the waiver are published in the Florida Medicaid coverage policies and the Sunshine Health provider manual. Facilities must hold current Florida AHCA (Agency for Health Care Administration) licensure at the applicable level of care — Level I, Level II, or detoxification — before Medicaid reimbursement is available. Confirm current Florida SUD waiver status and facility eligibility with Sunshine Health UM before admitting Medicaid members to a residential program.

How do I credential with Sunshine Health?

Sunshine Health uses CAQH ProView as its primary credentialing data source. Ensure your CAQH profile is fully attested with current Florida licensure, NPI, malpractice coverage, and applicable AHCA facility certifications before submitting a Sunshine Health network application. Florida Medicaid enrollment through FMMIS (Florida Medicaid Management Information System) is a prerequisite — complete FMMIS enrollment before or concurrently with your Sunshine Health application. After receipt of a complete credentialing package, the process typically takes 90 to 120 days. Contact the Sunshine Health provider services team through sunshinehealth.com/providers for network application forms and current requirements.

Claims, denials, and follow-up

Claims and status workflows vary by plan, state, and network arrangement. Start with the Sunshine Health provider portal or the payer instructions listed on the insurance profile, then confirm member-specific payer routing, authorization requirements, and claim format before billing.

Before claim submission, confirm the payer route, authorization number, billed level of care, rendering and facility identifiers, date range, and whether another payer is primary. When a claim stalls, work backward from the portal record to the VOB, authorization, and documentation packet.

Where fits after the portal

The Sunshine Health portal may answer one part of the case. helps treatment centers keep portal findings connected to admissions, clinical documentation, authorization status, claim follow-up, and denial work.