Sunshine Health Billing Guide for Behavioral

• SH
• Medicaid MCO

Sunshine Health

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

Quick Reference

Payer Type

Medicaid MCO

Parent Company

Centene Corporation

Headquarters

Sunrise, FL

Provider Portal

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Portal Guide

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Credentialing

CAQH ProView plus Florida Medicaid enrollment (FMMIS)

Timeline

90-120 days

Coverage

1 states

Last Verified

Apr 19, 2026

Published

Apr 19, 2026

Reading Time

10 min

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

Medical Necessity Criteria

• Florida Medicaid Clinical Coverage Policies
• ASAM Criteria (for SUD level of care determinations)
• Florida Medicaid mental health criteria

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Overview

Sunshine Health is Centene Corporation’s Florida Medicaid managed care plan, headquartered in Sunrise, Florida, and one of the largest Medicaid managed care organizations operating in the state. Sunshine Health participates in Florida’s Statewide Medicaid Managed Care (SMMC) program, serving Medicaid members across Florida’s Medicaid regions. The plan’s roots trace to the original Sunshine Health plan that operated in Florida before Centene’s expansion, and the brand was further consolidated following Centene’s 2020 acquisition of WellCare Health Plans, which absorbed WellCare of Florida’s Florida Medicaid operations into the Sunshine Health brand. Today, Sunshine Health operates as Centene’s primary Florida Medicaid vehicle, while WellCare in Florida focuses primarily on Medicare Advantage.

As a wholly owned Centene subsidiary, Sunshine Health benefits from Centene’s national managed care infrastructure, data analytics, and operational scale while operating under Florida’s state-specific Medicaid contract terms. Florida’s SMMC program is administered by the Agency for Health Care Administration (AHCA) and encompasses Managed Medical Assistance (MMA) for physical and behavioral health and Long-Term Care (LTC) for elderly and disabled members. Sunshine Health participates in the MMA program, which includes the behavioral health benefit that is the focus of this guide.

For behavioral health treatment providers in Florida, Sunshine Health is one of the most important Medicaid payer relationships, given Florida’s large Medicaid population and its persistent challenges with SUD — particularly opioid and stimulant use disorders in South Florida, Central Florida, and the I-4 corridor. Florida has the third-largest Medicaid population in the country, and Sunshine Health’s enrollment makes it a dominant presence in the Florida Medicaid managed care landscape. Providers should be familiar with Florida’s SMMC program structure, the role of AHCA in setting coverage policy, and the specific SUD treatment facility certification requirements administered by AHCA’s licensing division.

Behavioral Health Coverage

Sunshine Health covers behavioral health services as part of Florida’s SMMC Managed Medical Assistance program, following the Florida Medicaid Clinical Coverage Policies published by AHCA. Behavioral health services under the MMA benefit include outpatient individual and group therapy, psychiatric evaluation and medication management, intensive outpatient programs (IOP), partial hospitalization programs (PHP), crisis stabilization, and medication-assisted treatment for opioid and alcohol use disorders. Florida’s SUPPORT Act compliance means that all FDA-approved MAT medications — buprenorphine, naltrexone, and methadone in appropriate settings — are covered through Florida Medicaid.

Florida Medicaid has historically used Behavioral Health Organizations (BHOs) to manage behavioral health benefits in several regions as a carve-out from the standard MMA contract. As Florida’s SMMC program has evolved, the BHO structure has been modified or integrated into MCO contracts in some regions. As of recent SMMC contract renewals, Sunshine Health generally manages behavioral health benefits directly as part of its integrated MMA contract in most Florida Medicaid regions. However, the benefit structure may differ by region, and providers should confirm the applicable benefit management arrangement with Sunshine Health for their specific geographic area before relying on this characterization.

Residential SUD treatment coverage under Sunshine Health follows Florida Medicaid coverage policy for SUD treatment facilities. Florida AHCA licenses SUD treatment facilities at multiple levels — including residential Level I (long-term) and Level II (short-term) and detoxification facilities — and Medicaid payment requires appropriate AHCA licensure. The federal IMD exclusion has historically limited Medicaid payment for residential SUD treatment in facilities with more than 16 beds, and Florida has pursued 1115 SUD waiver authority to expand residential coverage for qualifying facilities. Confirm the current Florida SUD waiver status and your facility’s AHCA licensure eligibility before admitting Sunshine Health members to residential programs.

The Florida Medicaid mental health benefit covers most outpatient and community mental health services, with inpatient psychiatric hospitalization generally covered subject to prior authorization. Medical necessity for SUD services follows the ASAM Criteria framework as interpreted through Florida Medicaid coverage policy. For mental health services, Florida Medicaid uses its own clinical coverage criteria published by AHCA. Documentation should align with the applicable Florida Medicaid clinical criteria and the Sunshine Health provider manual for the service type being authorized.

Credentialing and Provider Enrollment

Sunshine Health uses CAQH ProView as its primary credentialing data source, consistent with Centene’s national approach across its subsidiaries. Before submitting a Sunshine Health network participation application, ensure that all individual clinicians and your facility have fully attested, current CAQH ProView profiles. The profile must include current Florida professional licensure, NPI and taxonomy codes, professional liability coverage, and applicable AHCA facility certifications for behavioral health service levels.

Florida Medicaid enrollment through FMMIS (Florida Medicaid Management Information System), administered by AHCA, is a prerequisite for joining the Sunshine Health provider network. Enroll through the Florida Medicaid Provider Enrollment portal on the AHCA website before or concurrently with your Sunshine Health application. Florida FMMIS enrollment requires submission of applicable AHCA facility licensure, NPI, Medicaid provider type and specialty documentation, W-9, and other required items. The FMMIS enrollment process can take several weeks; claims will not pay until FMMIS enrollment is active.

For SUD treatment facilities, AHCA facility licensure at the applicable level of care (outpatient, residential Level I or Level II, or detoxification) is required in addition to standard FMMIS enrollment. Behavioral health facilities should also ensure they hold any required DCF (Department of Children and Families) licensure for programs serving specific populations, including adolescents and dual-diagnosis members.

After receipt of a complete credentialing application, Sunshine Health credentialing typically takes approximately 90 to 120 days. Recredentialing occurs on a standard three-year cycle. Contact the Sunshine Health provider services team through sunshinehealth.com/providers for the current network application and credentialing checklist, as requirements can change with SMMC contract renewals.

Verification of Benefits (VOB)

Benefit verification for Sunshine Health members requires a two-step process. First, confirm active Florida Medicaid enrollment and SMMC MCO assignment through the FMMIS eligibility verification system. Use the AHCA Florida Medicaid provider portal, the Florida Medicaid automated eligibility verification line, or a standard HIPAA 270/271 transaction through your clearinghouse to confirm that the member is enrolled in Florida Medicaid and assigned to Sunshine Health on the date of service. Florida has multiple competing SMMC MCOs, and member assignments change — a member who was with Sunshine Health in a prior month may have been reassigned.

Second, verify plan-specific behavioral health benefits, covered services, authorization requirements, and any applicable BHO carve-out arrangements through the Sunshine Health provider portal at sunshinehealth.com/providers. The portal provides eligibility inquiries, benefits detail, authorization tracking, claim status, and access to state-specific provider manuals and billing guides. For detailed behavioral health VOB — particularly for residential services, PHP, or members with potential BHO carve-out — contact Sunshine Health provider services. Provider services contact information is available on sunshinehealth.com/providers and on the member’s Sunshine Health insurance card.

Florida Medicaid eligibility can change monthly based on redetermination cycles. Re-verify on or near every date of service. Medicaid is the payer of last resort in Florida — screen for commercial insurance, Medicare, TRICARE, or VA coverage that would take primary position before billing Sunshine Health. Document each VOB with date, representative name, reference number, the benefits confirmed, and any authorization requirements identified.

Prior Authorization Requirements

Sunshine Health requires prior authorization for residential SUD treatment, medically managed detoxification, inpatient psychiatric hospitalization, and partial hospitalization programs. IOP and intensive behavioral health services may also require authorization — confirm the current requirements in the Sunshine Health provider manual, as Florida SMMC MCO authorization rules evolve with contract renewals. Outpatient therapy and office-based MAT with buprenorphine or oral naltrexone typically do not require prior authorization under Florida Medicaid managed care.

Authorization requests are submitted through the Sunshine Health provider portal, by phone to the utilization management team, or by fax — confirm the preferred method with Sunshine Health or in the current provider manual. Clinical documentation should cover the member’s diagnoses, presenting symptoms, substance use or psychiatric history, current functional status, prior treatment episodes, and the proposed treatment plan. For SUD services, organize the clinical narrative around the six ASAM Criteria dimensions. For mental health services, follow Florida Medicaid clinical coverage criteria.

Concurrent reviews for residential and inpatient services are required at intervals established in the Sunshine Health provider manual and consistent with Florida SMMC MCO contract requirements. Residential SUD concurrent reviews are typically required every 5 to 10 days; inpatient psychiatric reviews may occur more frequently. PHP reviews generally occur every 7 to 14 days. Each review requires updated clinical documentation of treatment progress, ongoing medical necessity, and active discharge planning. If a continued-stay authorization is denied, request a peer-to-peer review with the Sunshine Health medical director before filing a formal Florida Medicaid appeal.

Claims and Billing

Sunshine Health accepts electronic claims through standard EDI 837I (institutional, UB-04) and 837P (professional, CMS-1500) formats submitted via clearinghouses, and through the Sunshine Health provider portal. Electronic submission is strongly preferred. Confirm the correct Sunshine Health payer ID with your clearinghouse — Sunshine Health uses its own payer ID distinct from WellCare and other Centene Florida subsidiaries. Using the incorrect payer ID will result in rejection or misdirected claim processing.

Billing codes, modifiers, and reimbursement rates follow the Florida Medicaid fee schedule and the Sunshine Health provider agreement. Florida Medicaid uses a combination of CPT codes for mental health services, H-codes for SUD outpatient and intensive services, and HCPCS codes for MAT medications and certain SUD residential encounters. Residential SUD services must be billed using the correct revenue and procedure codes aligned with the applicable AHCA licensure level. The current Sunshine Health billing guide and Florida Medicaid billing guidelines are available through sunshinehealth.com/providers.

Timely filing for Sunshine Health Medicaid claims follows Florida SMMC MCO contract requirements. Florida Medicaid managed care contracts generally require initial claim submission within 180 days of the date of service, though your Sunshine Health provider agreement may specify a different window. Corrected claims and coordination-of-benefits submissions have separate timely filing requirements. Late Medicaid claims have very limited recourse under Florida Medicaid rules — build timely filing alerts into your billing system and submit claims well in advance of the deadline.

Common denial reasons include missing prior authorization, member not enrolled in Florida Medicaid or assigned to a different SMMC MCO on the date of service, AHCA licensure mismatch for the level of care billed, incorrect billing codes or modifiers, duplicate submission, and third-party liability issues. In regions where a BHO carve-out exists, inadvertent cross-billing between Sunshine Health and the BHO is also a common error. Track denial reason codes systematically to identify systemic billing issues.

Key Contact Information

Sunshine Health serves: Florida (Statewide Medicaid Managed Care, Managed Medical Assistance)

• Provider Portal: https://sunshinehealth.com/providers ↗ (primary portal for Sunshine Health network providers in Florida)
• Credentialing: CAQH ProView ( https://proview.caqh.org ↗ ) plus Florida Medicaid FMMIS enrollment; contact Sunshine Health provider network through sunshinehealth.com/providers
• Florida Medicaid Enrollment (FMMIS): AHCA Florida Medicaid Provider Enrollment — ahca.myflorida.com/Medicaid
• Prior Authorization: Submit through sunshinehealth.com/providers or by phone/fax to Sunshine Health UM; contact information on the member’s insurance card and provider portal
• Verification of Benefits: FMMIS for state eligibility + sunshinehealth.com/providers for plan benefits; call provider services for detailed BH benefit confirmation
• Claims Submission: Electronic 837I / 837P via clearinghouse (Sunshine Health-specific payer ID) or sunshinehealth.com/providers
• Florida AHCA Facility Licensure: Agency for Health Care Administration — ahca.myflorida.com (SUD and behavioral health facility licensing)
• Parent Organization: Centene Corporation — centene.com

Frequently Asked Questions

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.

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.

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.

Florida Medicaid has historically managed behavioral health through a combination of MCO-managed benefits and, in some regions, Behavioral Health Organizations (BHOs) that administered behavioral health carve-outs. Florida's Statewide Medicaid Managed Care (SMMC) program has evolved the benefit structure over time. Sunshine Health generally manages behavioral health services — including mental health and SUD treatment — directly as part of its integrated MCO contract under the SMMC program. However, the specific carve-out or integration structure may vary by Florida Medicaid region and may have changed with recent SMMC contract renewals. Confirm whether behavioral health services are managed by Sunshine Health directly or through a separate BHO arrangement for the specific Medicaid region in which your facility operates before submitting authorizations or claims.

Timely filing for Sunshine Health Medicaid claims follows Florida Medicaid MCO contract requirements. Florida Medicaid managed care contracts generally require initial claim submission within 180 days of the date of service, though your specific Sunshine Health provider agreement may specify a different window. Corrected claims and coordination-of-benefits submissions typically have separate, shorter deadlines. Always reference the current Sunshine Health provider manual or your provider agreement for the controlling deadline, as Florida Medicaid rules can change with SMMC contract renewals. Late Medicaid claims have extremely limited appeal rights under Florida Medicaid rules, so build timely filing alerts into your billing system from the first date of service.

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