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SHPBN-2016-079 Retro-eligibility Notification Process Update

Date: 11/14/16

The following is an update to Sunflower Health Plan’s retro-eligibility process that was released February 2016. This notification process is effective immediately (November 1, 2016).

Member eligibility determination date by state is after a service is provided for a covered timeframe (REVISED):

  • Example: Member is inpatient or received another covered service from 11/1/16-11/5/16, the state determines the member eligible on 11/8/16 back dating to 11/1/16.
  • Sunflower will be asking for minimal information including: a fully completed authorization form with final inpatient face sheet or similar for an outpatient service.
    • Please fax the above to 888-453-4316, clearly indicating "Retro Eligible" on the prior authorization request form.
    • The provider can submit a claim for payment after receiving an approval letter with authorization.
    • Provider should be aware of the 180-day timely filing from date of eligibility determination to allow for sufficient time to process the claim. Claim will be denied if not submitted timely.
    • Reminder, all claims are subject to any post-payment review by Sunflower.
  • NOTE: If the provider submits the claim without sending the information above and receiving an authorization and notification, the claim will be denied and can be submitted for reconsideration. See reconsideration process below.

Member is inpatient or receiving a service when eligibility is determined by the state:

  • Example: Member goes inpatient on 11/1/16, the state determines the member eligible on 11/8/16 back dating to 11/1/16 and the member is still in the hospital or receiving another covered service.
  • Notify Sunflower Health Plan to obtain an authorization and facilitate care and discharge planning when you discover eligibility before a member is discharged from the hospital or service.
  • Provider should fax clinical information with completed prior authorization request form to 888-453-4316 and note "Retro Eligible" on the prior authorization request form to start the authorization process. 
  • The provider can submit a claim for payment after receiving an approval letter with authorization.
  • Hospital days prior to notification will not be denied for late notification.
  • NOTE: If the provider submits the claim without sending the information above and receiving an authorization and notification, the claim will be denied and can be submitted for reconsideration. See reconsideration process below.

If claim denied for no authorization:

You may request to have the claim denial reconsidered. To have claim denial reconsidered based on retro-eligibility determination, the provider should send in a claims reconsideration along with clinical information and a cover sheet indicating "Retro Eligible" to the following address:

Attn: Reconsiderations
Sunflower Health Plan
P.O. Box 4070
Farmington, MO, 63640-3833

Determination, notification and payment will follow standard claim processing timelines.

Provider should be aware of the 180-day timely filing from date of eligibility determination. Claim will be denied if not resubmitted timely.

 

If you have questions about this bulletin or other provider resources, please call Customer Service at 1-877-644-4623.