Sunshine State Health Plan, Timely Filing Limit

The most important thing to confirm with Sunshine State Health Plan, is not just the number of days, but also what event starts the clock. Some payer documents measure from date of service, some from discharge, and some publish different rules for corrected claims or appeals.

At a glance

• Sunshine Health’s Florida Medicaid provider guidance states the initial claim filing limit is 180 calendar days from date of service for participating providers and 365 calendar days for non-participating providers. Corrected claims or reconsiderations/claim disputes must generally be received within 90 days from the explanation of payment or denial notification; second-level disputes also have a 90-day limit from the first-level decision correspondence. For coordination of benefits, the guidance uses the primary payer explanation-of-payment date and applies 90-day or 180-day limits depending on participating status, with specific table instructions.

Initial claim filing limits

• Participating providers: 180 calendar days from date of service
• Non-participating providers: 365 calendar days from date of service
• COB: 90 days/180 days as reflected in the table, measured from the primary payer EOP date, depending on participating status and the stated table rules

Corrected claim filing limits

• 90 calendar days from the date of the original explanation of payment or denial
• Second-level reconsideration/claim dispute: 90 calendar days from the date on the first-level decision correspondence

Appeal and reconsideration deadlines

• Claims-related complaint deadline: 90 days from the date of the final determination of the primary payer for claims-related complaint issues (provider complaints page)
• A second-level reconsideration/claim dispute must be received within 90 days from the date indicated on the first-level decision correspondence

Trigger basis and caveats

• Initial claim filing is measured from date of service to date received by Sunshine Health.
• Reconsideration/claim dispute timing is measured from the explanation of payment/correspondence or denial to the date received by Sunshine Health.
• COB timing is measured from the primary payer explanation of payment to the date received by Sunshine Health.
• Timely filing can vary by provider participation status and claim category.
• Some pages reference claim reconsideration/adjustment procedures separately from formal appeals and provider complaints.
• Medicare-Medicaid crossover claims have separate filing rules; the reviewed guidance states the filing limit is the greater of 36 months from date of service or 12 months from Medicare adjudication date.

Provider resources

• Sunshine Health Provider Portal & Resources (official)
• Florida Provider Resources | Florida Medicaid | Sunshine Health (official)
• General Quick Reference Guide for Providers (official)
• Provider Support Guide (official)
• Contact Us (official)
• Provider Complaints (official)

Sources