Plan Policies
This policy requires approval before certain specialty or high-cost services are provided.
What is Prior Authorization
Before discussing benefits with a caller, representatives must first complete this process.
What is Member and/or Provider Verification
Providers contact this department to verify a member's eligibility and benefits. The department also assists healthcare providers with questions about claims, authorizations, eligibility, and billing.
What is Provider Services.
This vendor provides vision benefits, including routine eye exams and eyeglasses for eligible members
What is Envolve Vision
This city is home to Walt Disney World Resort.
What is Orlando
This federal requirement protects member health information and privacy
What is HIPAA
This procedure requires agents to record details of every member interaction
What is Documentation
This department investigates member/ providers complaints and handles requests for reconsideration of coverage decisions.
What is Grievances and/or Appeals
This vendor provides non-emergency transportation services to help members get to and from covered medical appointments
What is Alivi
This is the capital city of Florida
What is Tallahassee
This policy gives members the right to dispute a denied service or benefit decision
What is the Grievance and/or Appeals Policy
This procedure is used when a member/provider issue request immediate management.
What is an Escalation
This department assists members with questions about benefits, coverage, ID cards, and provider information.
What is Member Services
This vendor manages pharmacy benefits and helps members access covered prescription medications
What is ExpressScripts
Florida is nicknamed this because of its warm climate and abundant sunshine
What is the Sunshine State
This policy outlines the standards providers must follow when caring for members.
What is provider Compliance
This procedure helps ensure calls meet state plans and regulatory standards, allowing calls to be recorded.
What is Quality
This department helps members manage chronic conditions and complex healthcare needs.
What is Care Management
This vendor helps provide Coverage of Services (DME, Home Health)
The president of Sunshine Health.
Who is Charlene Zein
This company is the parent organization of Sunshine Health.
What is Centene Corporation
Sunshine Health may offer rewards for members who complete activities such as annual wellness visits and preventive screenings
What is a Member Rewards Program
This team assists with provider education and training while also helping recruit and maintain provider network participation.
What is Provider Relations or PEAM
Cardiac Imaging, Complex imaging, CT, PET, MRA, MRI, High Tech Radiology, and Musculoskeletal procedures need to be authorized by
What is Evolent/ RadMD
This large reptile is commonly found in Florida's lakes, rivers, and swamps
What is an alligator