Claims Filing Deadlines

Sunshine Health Electronic Claims Filing Deadlines

Original claims (first time claims) and corrected claims must be submitted to Sunshine Health within 180 calendar days from the date services were rendered or compensable items were provided. When Sunshine Health is the secondary payer, claims must be received within 90 calendar days of the final determination of the primary payer. Claims received outside this timeframe will be denied for untimely submission.

Medicare crossover claims should not exceed a period of 3 years from date of service. All requests for reconsideration or provider disputes must be received within 90 days from the original date of notification of payment or denial. Prior to processing will be upheld for provider claim requests for reconsideration or disputes received outside the 90 days’ timeframe, unless a qualifying circumstance is offered and appropriate documentation is provided to support the qualifying circumstance.

Qualifying circumstances include:

  • Catastrophic event that substantially interferes with normal business operations of the provider or damage or destruction of the provider’s business office or records by a natural disaster.
  • Mechanical or administrative delays or errors by Sunshine Health or the Florida
  • Department for Medicaid Services.
  • The member was eligible however the provider was unaware that the member was eligible for services at the time services were rendered. Consideration is granted in this situation only if all the following conditions are met:
    • The provider’s records document that the member refused or was physically unable to provide their ID card or information.
    • The provider can substantiate that he continually pursued reimbursement from the patient until eligibility was discovered.
    • The provider has not filed a claim for this member prior to the filing of the claim under review.

To learn more about EDI Claims and become a certified EDI Professional, please visit our course schedule page.

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