Forms & Documents for Providers
Now Available
Special Needs Plan (SNP) Model of Care Training & Medicare Compliance Program Guidelines
New: Inpatient Readmissions Reimbursement Policy
Effective July 1, 2025, separate reimbursement may not be used for claims that have been identified as readmission to the same hospital within 30 days of discharge for the same, similar, or related condition unless provider, federal, or CMS contracts and/or requirements indicate otherwise.
This policy only affects facilities reimbursed for inpatient services by a diagnosis related group methodology.
Policy exclusions:
- Admissions for the medical treatment of: Cancer, Neonatal/newborn, Obstetrical deliveries, Behavioral health, Rehabilitation care, Sickle cell anemia, Transplants
- Transfers from one acute care hospital to another
- Member discharge from the hospital against medical advice
For policy details, refer to the Provider Manual 2025.
Social Services Announcement
This is a reminder about the invaluable support available through our Social Services Department. The department is dedicated to assisting members in addressing non-medical needs that impact well-being and care outcomes.
Services Provided Include:
- Telephonic assessments: To evaluate member’s needs and strengths. It aims to identify resources and support systems.
- Community Resources: Help connecting members to housing, food assistance, financial aid, and other local resources.
- Behavioral Health Support: Referrals for counseling or mental health services.
- Member Education: Resources to promote self-sufficiency and empower individuals.
Special supplemental benefits for the chronically ill (SSBCI) Eligibility Changes
Effective January 1, 2025, HealthSun Health Plans, Inc. (HealthSun) will change its process for approving members for special supplemental benefits for the chronically ill (SSBCI), such as groceries, utilities, chronic meals (for more than 90 days), and nonemergency transportation to non-health-related destinations.
Special Supplemental Benefits for the Chronically Ill (SSBCI) Eligibility Changes Bulletin
Special Supplemental Benefits for the Chronically Ill (SSBCI) HealthSun Provider Form
Provider Notices and Updates
Provider Announcements
- *Shift to Fax for Pre-Certification Approval Notifications Notice July 11, 2024
- Attention HealthSun Providers, effective 01/01/2020, HealthSun will be changing to a new Pharmacy Benefit Manager (PBM)
- Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency
- New Behavioral Health vendor effective 03/01/2023
- Notice of Health Plan Accreditation Survey - December 4th to December 6th, 2023
- Provider Payment Notification 10/2023
- Social Services Bulletin
- Update to the Model Admission Questions for Providers to Ask Medicare Beneficiaries
Telemedicine Information for Providers
Archive
- 2020 Hurricane Preparedness and Planning
- Adult Elective Surgery and Procedures Recommendations
- Ambulatory Surgical Centers (ASCs) Temporarily Enrolling as Hospitals
- Electronic Prescribing - House Bill 831
- General Telemedicine Toolkit
- HealthSun EXPRESS COVID 19 Medicare Telehealth FAQ
- Jimmo v. Sebelius Internal Training for Staff
- Long Term Care Facility Guidance
- New Medicare Part D Prescription Opioid Policies for 2019 (Prescriber Webinar)
- New Medicare Part D Prescription Opioid Policies for 2019 (Tip Sheet)
- Provider Manual 2023
- Provider Manual 2024
- Telehealth Waiver FAQ
HealthSun Health Plans FDR Compliance
HealthSun Health Plans FDR Compliance
Clinical Practice and Preventive Guidelines
Clinical Practice and Preventive Guidelines
Additional Provider Forms
Provider Forms
- 2025 Step Therapy Criteria Part B Drugs only – 07/01/2025
- Functional Mobility Evaluation Form (FME)
- OTC - Placing OTC Orders 2025
- Participating Provider Dispute Form
- Plan Of Care Form (POC)
- Pre-Cert Form
- Provider Manual 2025
- Social Services Referral Form
- Specialty Medication Request Form
- Waiver of Liability Form
Provider Portal Access
To apply for access to the portal, please complete application provided below. Please note, if you are a non participating provider, you are required to fill out the BA Agreement provided below. Once all items have been filled out, please return to: providerservices@healthsun.com.
