Claim Requests

Claim Requests for Reconsideration, Provider Disputes and Corrected Claims (Sunshine Health Guidelines) Provider billing department will need to submit to the appropriate payer to prevent payment delays. The provider should use the same date of service guidance on the first page to determine the correct payer. Corrected claims must be submitted within 90 days from the date Read More →


The New England Electronic Commerce Users Group (NEECOM) Spring Conference is just 4 weeks away Attention All B2B/EDI, AP, Purchasing, and Supply Chain Professionals. The New England Electronic Commerce Users Group (NEECOM) is thrilled to announce that it is back for an IN PERSON NEECOM Spring Conference this May 18th-19th, 2022 in Westborough MA at the Doubletree Read More →

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 Read More →

Mapping Guides: EDI Claims

Sunshine Health Electronic Claims Guidelines It is important that providers ensure Sunshine Health has accurate billing information on file. Provider should confirm with the Provider Relations department that the following information is current in Sunshine Health files: Provider name (as noted on current W-9 form) National Provider Identifier (NPI) Tax Identification Number (TIN) Taxonomy code Physical Read More →

Electronic Claims Submission

Basic Guidelines For Electronic Claims Submission Sunshine State Health Plan, Inc., hereafter referred to as Sunshine Health, is required by state and federal regulations to capture specific data regarding services rendered to its members. The provider must adhere to all billing requirements in order to ensure timely processing of claims and to avoid unnecessary rejections Read More →

Claims Authorization Process

Authorization Process Guides For WellFirst Health Providers WellFirst Health’s goal is to provide high quality, cost-effective care, at the right time and in the right setting for members. The UM Department maintains processes to ensure: (a) equitable access to care across the network and (b) the most appropriate use of medical services in accordance with member Read More →

EDI Claims Appeal

Provider Appeals Process (WellFirst Health Electronic Claims Guides) If WellFirst Health denies a claim or benefit that results in a partial payment, denial to a practitioner, or makes a determination that is unsatisfactory to the practitioner, the practitioner of care is entitled to appeal the denial. Appeal requests submitted in writing will be considered by Read More →

Claims Coding

Claims Coding (WellFirst Health EDI Claims) WellFirst Health is committed to processing claims in a consistent, timely and accurate manner. To support this ongoing effort, claims processing logic is maintained to support the application of correct coding principles and HIPAA codeset standards. These payment policies are derived from recommendations from a variety of clinical and Read More →

Claims Payment Adjustments

EDI Claims Payment Adjustments (WellFirst Health) When either WellFirst Health or a provider determines that payment has been made for services for which payment should not have been made, the provider should promptly return such overpayments to WellFirst Health. Upon the discovery of any such overpayments, WellFirst Health may alternatively offset such overpayments against any Read More →

HIPAA Taining

Grace period for advanced premium tax credit subsidy (WellFirst Health Electronic Claims Guidelines) ACA mandates a three-month grace period before terminating coverage for members who purchased their health plan on the Marketplace and who also meet certain income thresholds to qualify for the Advanced Premium Tax Credit (APTC) subsidy. The grace period applies after the Read More →