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 of service. All claim requests for reconsiderations and provider disputes must be received within 90 days from the date of original notification of payment or denial was issued. If a provider has a question or is not satisfied with the information they have received related to a claim, there are five effective ways in which the provider can contact Sunshine Health.

  1. Review the claim in question on the secure Provider Portal:
    • Participating providers, who have registered for access to the secure provider portal, may access claims to obtain claim status, submit claims or submit a corrected claim.
  2. Contact a Sunshine Health Provider Service Representative at 1-844-477-8313:
    • Providers may inquire about claim status, payment amounts or denial reasons. A provider may also make a simple request for reconsideration by clearly explaining the reason the claim is not adjudicated correctly.
  3. Submit an Adjusted or Corrected Claim to SunshineHealth:
    • Corrected claims must clearly indicate they are corrected in one of the following ways:
      • Submit corrected claim via the secure Provider Portal. Follow the instructions on the portal for submitting a correction o Submit corrected claim electronically via Clearinghouse
      • Corrected and/or Voided Claims are subject to Timely Claims Submission (i.e., Timely Filing) guidelines. To submit a Corrected or Voided Claim electronically: For Institutional claims, provider must include the original Sunshine Health claim number for the claim adjusting or voiding in the REF*F8 (loop and segment) for any 7 (Replacement for prior claim) or 8 (Void/cancel of prior claim) in the standard 837 layout. For Professional claims, provider must have the Frequency Code marked appropriately as 7 (Replacement for prior claim) or 8 (Void/cancel of prior claim) in the standard 837 layout. Any missing, incomplete or invalid information in any field may cause the claim to be rejected.
    • Submit a “Request for Reconsideration” to SunshineHealth:
      • A request for reconsideration is a written communication (i.e. a letter) from the provider about a disagreement in the way a claim was processed but does not require a claim to be corrected and does not require medical records.
      • The request must include sufficient identifying information which includes, at a minimum, the patient name, and patient ID number, date of service, total charges and provider name.
      • The documentation must also include a detailed description of the reason for the request.

A provider dispute is to be used only when a provider has received an unsatisfactory response to a request for reconsideration. If the original decision is upheld, the provider will receive a revised EOP or letter detailing the decision. Sunshine Health shall process, and finalize all corrected claims, requests for reconsideration, and/or disputed claims to a paid or denied status within 90 calendar days of receipt of the corrected claim, request for reconsideration or provider dispute.

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

Leave a Reply

Your email address will not be published.

Post Navigation