FAQs

The services that require Prior Authorization can be found in the Provider Manual as well as posted in the Resources Section. Additionally, Sunflower offers a procedure lookup tool on our website. You can enter a CPT, HCPCs, or UB04 code to check for authorization requirements.

Sunflower has adopted utilization review criteria developed by McKesson InterQual® products to determine medical necessity for healthcare services. InterQual appropriateness criteria are developed by specialists representing a national panel from community-based and academic practice.

InterQual is utilized as a screening guide and is not intended to be a substitute for practitioner judgment. The Medical Director, or other healthcare professional that has appropriate clinical expertise in treating the member’s condition or disease, reviews all potential adverse determination and will make a decision in accordance with currently accepted medical or healthcare practices, taking into account special circumstances of each case that may require deviation from the norm in the screening criteria.

The member and provider are required to follow the rules of the primary payor. If the primary payor denies for administrative reasons, Sunflower will NOT coordinate with the primary insurance. If the primary payor denies for non-administrative reasons, the provider will be required to obtain an authorization for any service Sunflower would otherwise require an authorization if Sunflower had been the primary payor.

Yes.

Yes.

The member and provider are required to follow the rules of the primary payor. If the primary payor denies for administrative reasons, Sunflower will NOT coordinate with the primary insurance. If the primary payor denies for non-administrative reasons, the provider will be required to obtain an authorization for any service Sunflower Health Plan would otherwise require an authorization if we were the primary payor.

Sunflower will post this information in the Provider Resources section of the website

Yes, by choosing the Behavioral Health selection in the Sunflower Provider Portal and pressing “Go.”

Please refer to the Authorization Guidelines in the Provider Manual.

Yes.

Providers can submit electronic claims in multiple ways:

• Batch or direct data entry via the secure provider portal
• Via KMAP’s Clearinghouse
• Via a clearinghouse partnered with Sunflower directly:
  • Payer ID:
    • 68069 – Medical
    • 68068 – Behavioral
  • Clearinghouse: Availity

Yes.

Sunflower’s website displays all provider bulletins. For immediate updates related to billing and claims payments, it’s important to sign up for the Email Alerts.

“Care management is a collaborative process of assessment, planning, facilitation, care coordinator, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communation and available resources to promote quality, cost-effective outcomes.” (Case Management Society of America® 2017)

If a member is receiving Home and Community Based Services (HCBS), Work Opportunities Reward Kansans (WORK), Children and Youth with Special Health Care Needs (CYSHCN), they will automatically enroll in care management.

These are just a few categories of members to whom Sunflower offers care management services.  If a member has complex physical or behavioral health needs or needs assistance in accessing community resources in order to coordinate care, then then a case manager may be requested.

Sunflower uses a multidisciplinary team approach that can include physicians, nurses, social workers, behavioral health professionals, chronic disease specialists and pharmacists. Focusing on the whole person means partnering with our trusted providers to ensure members receive the right services, in the right place, at the right time. 

Providers may make the request through the secure portal. They may also call Customer Service toll free 1-877-644-4623 and request a care manager or ask to speak with a representative of the Care Management department. You may also access the Medical Management Territory Map that is located under Provider Resources. The map provides an email address for someone in the county where the member resides.

Yes.

Please fax to 1-877-851-3990.

Sunflower accepts electronic claims, claims submitted through our Secure Provider Portal or claims submitted through KMAP.

Sunflower uses payer ID number 68069 (68068 for behavioral health). Our preferred electronic claims warehouse is Availity.

Additionally, single or batch claims can be submitted free of charge through our Secure Web Portal. Registration for the Secure Web Portal takes about 5 minutes.

Paper claims are submitted to Sunflower or its benefit managers, depending on the service. Please see the Provider Manual or Provider Quick Reference Guide for specific information.

Providers must submit the Rendering Provider NPI to avoid claim rejection.

Sunflower has scheduled check runs two times a week. Our average claims payment turnaround time is 7 to 14 days for clean claims.

Yes.

No, only that line item will deny.

Yes.

Nursing assessments under the TA waiver have coverage of one every three months and the FE waiver one per lifetime. Wellness monitoring has coverage for one every 55 days under the FE waiver. These services require authorization.

Yes, unless the provider’s contract specifies that overpayments should be handled in a different manner.

Yes, clearinghouses not on our list will route the claims to Availity, which will send the claims on to Sunflower.

Yes, all providers must have a KMAP ID to obtain a contract with or receive payment from Sunflower.

Go to Contract Request Form. This form will ask you to complete some very basic information. You may also call us toll free 1-877-644-4623 (TTY: 711) to request a contract.

Yes, all providers must have a KMAP ID to obtain a contract with or receive payment from Sunflower Health Plan.

No, there are no co-pays for KanCare. However, some members have to cover a Spenddown requirement.

Yes.

Yes, you must be credentialed by Sunflower. Upon your written authorization, Sunflower will access your credentialing information on the CAQH (Council for Affordable Quality Health) website. Sunflower will also use the Kansas Final Joint Approved Credentialing Application for hospitals and ancillary providers. These documents will be included in the contract packet sent to you by Sunflower.

Yes.  Sunflower Provider Network Specialis teams are available to conduct orientations or in-service sessions.  Please contact Provider Relations at providerrelations@sunflowerhealthplan.com or toll free 1-877-644-4623 (TTY: 711).

Medicaid members can change their MCO during their 90 days of eligibility/assignment, then once/year during open enrollment. Members can change their PCP/providers at any time. To view Sunflower's provider directory, please click here.

Yes, members under:

• SSI
• HCBS
• LTC
• Medicare Advantage
  • Qualified Medicare Beneficiary (QMB)
  • Qualified Medicare Beneficiary Plus (QMB+)
  • Specified Low-Income Medicare Beneficiary Plus (SLMB+)
  • Full Benefit Dual Eligible (FBDE)

Members are auto-assigned to MCOs by the State. Claims for newborn services billed under the mother’s beneficiary ID will be pended for 45 days pending receipt of the newborn’s beneficiary ID number. 

See more details in the related bulletin, SHPBN-2016-086 OB Deliveries & Newborn Claims Billing Clarification.

HCBS services require an approved person centered service plan and resulting prior authorization.

FMS providers may verify eligibility, client obligation and authorizations for services and view claims payment status.

Yes, nursing facilities should follow the same process that exists today.  Continue to submit the form to the State.

Providers are required to keep the documentation required for billing each HCBS service as outlined within the KMAP HCBS manuals and approved HCBS waivers. Providers are not required to submit this documentation unless requested by Sunflower.

Sunflower Health Plan is a Medicaid Managed Care Organization (MCO) that serves the health needs of Kansans.

Sunflower has been contracted with the Kansas Department of Health and Environment (KDHE) – Division of Health Care Finance (DHCF) to serve Medicaid-eligible members through the KanCare Program effective January 1, 2013.

Sunflower began serving Medicare Advantage and Health Insurance Marketplace members in 2018.

We do this through our focus on the individual, whole health and local involvement. 

• Focus on individuals. We believe treating people with kindness, respect and dignity empowers healthy decisions and that healthier individuals create more vibrant families and communities.
• Whole health. We believe in treating the whole person, not just the physical body.
• Active local involvement. We believe local partnerships enable meaningful, accessible healthcare.

Sunflower is a subsidiary of Centene Corporation, which has more than 30 years of experience in the healthcare industry.

Upon completion of the contracting and credentialing process, you will be notified of your contract effective date and will receive a Provider Welcome Packet. This packet will include a copy of the provider manual, quick reference guides and other helpful forms.

Each office, hospital, clinic, and ancillary provider will be assigned a dedicated Provider Network Specialist. Your Provider Network Specialist will contact you to schedule an orientation to review the materials in the Provider Welcome Packet.

Your Provider Network Specialist will schedule periodic visits with you. In between the visits, you may visit this site for updates.

Additionally Sunflower has a local, dedicated provider call center to assist you with any questions that you might have. The local Provider Network Specialists can be reached toll free 1-877-644-4623 (TTY: 711) Monday through Friday 8:00 a.m. to 5:00 p.m.

For members who do not speak English or do not feel comfortable speaking it, Sunflower has a free service to help. This service is very important because you and your doctor must be able to talk about your medical or behavioral health concerns in a way you both can understand.

Our interpreter services are provided at no cost to you and can help with many different languages. This includes sign language. We also have Spanish-speaking representatives available who can help you as needed. Sunflower members who are blind or visually impaired can call Customer Service for an oral interpretation.

To arrange for interpretation services, call Customer Service toll free 1-877-644-4623 (TTY: 711).

Depends on the age of the member and needs of the member. Please refer to Bright Futures Periodicity Schedule (PDF).

More information about Kan-Be-Healthy and Early and Periodic Screening, Diagnostic, Treatment (EPSDT) can be found in our EPSDT Provider Reference Kit.

Yes, the Aging & Disability Resource Center (ADRC) will conduct the CARE Assessment.

Yes, for a skilled nursing facility stay, but not for a custodial stay.

Sunflower offers care management and transition coordination services through our contracted providers, which includes assistance with finding housing, household supplies and home evaluation for accessibility. Sunflower also offers transitional services, including one week of home-delivered meals, assistance with scheduling appointments and a wellness check post placement.

Yes, Sunflower has partnered with PaySpan Health to deliver a web based approach to EFT and ERA. This is a free service to providers. Register on the PaySpan website.

Call PaySpan at 1-877-331-7154 or e-mail them at providersupport@payspanhealth.com.  You must provide your tax ID number. You will then complete the registration process at www.payspanhealth.com.

PaySpan will then send a test deposit to the bank account specified during the registration process. You must verify the receipt of the test deposit and then you will be fully registered.  Electronic Remittance advice will begin immediately. If you have trouble with registration, please visit PaySpan's help page or contact your provider relations representative.

Yes, if the provider is a registered user for PaySpan.

Medicaid

Sunflower adheres to the State of Kansas Preferred Drug List (PDL) to determine medications that are covered under the pharmacy benefit. Please visit the KDHE (Kansas Department of Health and Environment) website to access the PDL.

Wellcare By Allwell

Information about Wellcare By Allwell drug coverage and PA can be found on the Wellcare By Allwell formulary web page. The coverage criteria are located on the Wellcare By Allwell utilization management page.

Ambetter

Information about Ambetter drug coverage and PA can be found on the Ambetter pharmacy resources page.

Medicaid

Sunflower also follows the Kansas Drug Utilization Review (DUR) Board approved prior authorization criteria. Please visit the KDHE pharmacy website for the PA criteria and PA forms.

Wellcare By Allwell

Information about Wellcare By Allwell drug coverage and PA can be found on the Wellcare By Allwell formulary web page. The coverage criteria are located on the Wellcare By Allwell utilization management page.

Ambetter

Information about Ambetter drug coverage and PA can be found on the Ambetter pharmacy resources page.

Paper referrals are not required for services at participating/contracted specialists. Members are educated to always consult with their primary care physician before accessing specialty services.

Member identification cards will be issued to all Sunflower members. Sunflower strongly encourages you to verify eligibility each and every visit. Eligibility can be verified through the Sunflower Secure Web Portal or by calling Customer Service toll free 1-877-644-4623 (TTY: 711). Additionally, eligibility may be accessed via the KMAP website.

Once registered on the Portal, you may do the following:

• Check member eligibility
• Submit prior authorization requests
• View patient lists
• View, adjust, void and submit claims.
• View payment history
• Submit reconsiderations and appeals
• And more...

You must be a contracted provider or have submitted a least one claim to Sunflower in order to register for the Secure Web Portal.

Yes.

Yes. In fact, we require that each individual have a sign-in rather than sharing a sign-in.

Yes, providers will receive a web reference number to view claim status.

Yes, providers can use the secure portal to correct paper claims, AuthentiCare claims, EDI claims, or claims submitted through the secure portal.

Yes, providers can use the secure portal to submit medical records. Please find the member via patient list or eligibility search, then go to the Document Resource tab for that member.

Yes

Sunflower offers a variety of added benefits to our members:

• Home Visiting - Community-based health services staff can provide in-home member visits to assist with scheduling healthcare appointments and transportation, as well as help with paperwork for benefits. They also assist members with accessing food, shelter, or other health or social programs. This service is complementary to case management and is performed by certified community health workers. 
• Nurse Line – 24-hour toll-free phone access to registered nurses who can answer medical questions and help members determine if their condition is an emergency
• My Health Pays^® – Rewards based incentives for achieving healthy behaviors and habits
• Start Smart for Your Baby – Education for pregnant and new mothers on how to grow and stay healthy
• Healthy Solutions for Life – Healthy Solutions for Life is a disease management program for members with asthma, COPD, diabetes, heart disease or high blood pressure. Members can enroll in any of these programs. Weight management through Sunflower’s Healthy Solutions for Life program has unlimited coaching. Members can participate in a smoking cessation program offered through Sunflower’s Healthy Solutions for Life program. Counseling treatment sessions are unlimited. Nicotine replacement therapy is a regular Medicaid benefit when prescribed by the doctor. 
• Chronic Disease Management & Depression Support – The program also helps members determine how emotions impact their condition. It helps with stress, poor sleep and appetite. As a part of the program, participants are assigned a health coach who works with the entire healthcare team to ensure members have everything they need to feel their best.
• MyStrength - Digital Behavioral Health - MyStrength digital behavioral health program has online tools to help members overcome depression and anxiety. MyStrength includes weekly exercises, mood trackers and daily inspirational quotes and videos. The program can be used on its own or with other care to support mental health.
• Tele Monitoring (Diabetes & Heart Failure) - In-home tele-health available for adults. This service helps members stay at home when they need help to manage their chronic conditions.

Due to their expertise in managing certain services, Sunflower contracts with specialty vendors.

• Radiology Imaging Services and Specialty Therapy and Rehabilitative Services – National Imaging Associates (NIA)
• Dental Services – Envolve Dental
• Vision Services – Envolve Vision
• Transportation Services – ModivCare

Provider manuals for the health plan and our specialty vendors can be found on the Provider Manuals, Forms and Resources page.

If Sunflower has been made aware of third party liability, this information will be posted on the eligibility section of our secure web portal.  Please continue to use the State’s TPL Provider Manual.

Yes. Transplants are a covered benefit.