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Recursos para proveedores | Ambetter de Sunshine Health
Recursos para proveedores
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Learn how Provider Engagement can help you. To find your Provider Engagement Account Manager (PEAM), select this link:
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Call Provider Services For Help
If you need help, call Provider Services at 1-877-687-1169 (Retransmisión de Florida: 1-800-955-8770) Monday through Friday from 8 a.m. to 8 p.m. Eastern. Stay up to date on Ambetter from Sunshine Health provider notices by reviewing and bookmarking Provider News.
Provider Forms
Training
Reference Materials
- 2026 Provider and Billing Manual (PDF)
- 2025 Provider and Billing Manual (PDF)
- Quick Reference Guide (PDF)
- Pharmacy Guide (PDF)
- Claims, Disputes & Recovery/CCU Guide (PDF)
- ICD-10 Information
- Payspan (PDF)
- Secure Portal (PDF)
- Telemedicine
- Referral and Authorization Information
- How to Secure Prior Authorization (PDF)
- Ambetter Health Hospital HH/DME Discharge Requirements QRG (PDF)
- Appointment Standards for Scheduling (PDF)
- Interpreter Request Form (PDF)
- Care Management (PDF)
Medical Management
- Pre-Auth Needed?
- Prior Authorization Guide (PDF)
- Inpatient Prior Authorization Form (PDF)
- Outpatient Prior Authorization Form (PDF)
- Outpatient Prior Authorization Requirements (PDF)
- Grievance and Appeals
- Prior Authorization Request Form for Non-Specialty Drugs (PDF)
- Prior Authorization Request Form for Specialty Medication (PDF)
- Notification of Pregnancy Form (PDF)
- Risk Adjustment Coding Guidelines
- Non-Formulary And Step Therapy Exception Request Form (PDF)
- Supplemental Outpatient Authorization Form (PDF)
Site of Care Optimization Program
Our Site of Care program focuses on patients receiving infusion therapies or specialty drugs in high-cost setting, such as hospitals. The goal is to transition eligible patients to clinically appropriate lower-cost alternatives — like home infusion or freestanding infusion centers — when suitable. Learn more about the Site of Care program.
Resources
- Infusion Therapy Site of Care Optimization Clinical Policy (FL.CP.PHAR.493) (PDF)
- Prescriber Quick Reference Guide: Site of Care Redirection (PDF)
- Site of Care Optimization Program Frequently Asked Questions (FAQs) (PDF)
Infusion Providers
| Provider Name | Services Offered | Phone Number | Fax Number | Nursing Services |
|---|---|---|---|---|
| AcariaHealth | Home | 855-535-1815 | 855-217-0926 | Yes |
| Accredo | Home or AIS | 888-773-7376 | 407-852-4926 | Yes |
| KabaFusion Boca Raton | Home or AIS | 877-309-2207 | 877-309-2209 | Yes |
| KabaFusion Orlando | Home or AIS | 800-421-5596 | 407-425-7445 | Yes |
| OptionCare | Home or AIS | 844-672-4842 | 888-979-8904 | Yes |
| BioHealth | AIS | 786-4606044 | 786-219-3917 | No |
| Capstone Vital Care | Home or AIS | 407-992-8494 | 407-992-8495 | Yes |
| Vital Care Panama City | Home or AIS | 850-388-4333 | 850-388-4338 | Yes |
| Prosper Infusion | Home or AIS | 877-380-3131 | 813-922-2457 | Yes |
Use Find a Provider tool for full list of in-network providers.
Behavioral Health
- Discharge Consultation Form (PDF)
- Discharge Planner Checklist (PDF)
- SMART Goals Fact Sheet (PDF)
- OTR Tip Sheet (PDF)
- Quality Rating System (QRS) Behavioral Health Measure Toolkit (PDF)
Claims and Claims Payment
Standards for Appointment Scheduling
Quality
- Quality Improvement (QI)
- Child and Adolescent Well Care Visits (WCV) (PDF)
- Practice Guidelines (PDF)
- Appropriate Treatment for Upper Respiratory Infection (URI) (PDF)
- Appropriate Testing for Pharyngitis (CWP) (PDF)
- Use of Imaging Studies for Low Back Pain (PDF)
- Pediatric HEDIS Measures (PDF)
- Providing Quality Care
- Supplemental Data System (SuDS) HEDIS Guide (PDF)
Emergency Room Alternatives
Fraud, Waste, and Abuse
Other
CMS Interoperability & Prior Authorization Final Rule: CY2025 Prior Authorization Requirements Reports and Metrics Summaries
In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.
Reports:
- Ambetter Health CMS Final Rule 0057-F Prior Authorization Requirements: 49004 & 86382 (PDF)
- Ambetter Health Prior Authorization Metrics Summary: 49004 (PDF)
- Ambetter Health Prior Authorization Metrics Summary: 86382 (PDF)
The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.