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 →