Why yes there's something wrong with eligibility this month on GAMMIS

UPDATE:

Some parents are also getting emails from DCH saying they're working on it...

Parents should email Emily Yona: emily.yona@dch.ga.gov

When my assistant Ruby and I were checking eligibility yesterday, we saw the issue online with eligibility for a lot of kids. She kept texting me, something is wrong. I kept agreeing. 

Here was what made us clue in: 

When  you would check a patient that had Katie Beckett or SSI and was active last month, this month their redetermination date was from last year long ago, something that would have triggered eligibility for January instead of now...

Some of the CMO kids are eligible with the CMO via their website, but not on GAMMIS

I don't know what the issue is, hoping it will be fixed, but from everything I'm seeing online, parents are stressed too with not being able to reach anyone at Medicaid today or DFCS. 

So it's up to you on whether you see the patients, but due note, if you do, you're taking a chance they do not have coverage. However, I would definitely recheck these after the 3^rd or 4^th day of this month, as often the eligibility changes/gets updated again then. Just stating on observation .

Caresource being Caresource

medicaid-ga-policy-reimburse-py-1428-20260201.pdf

Download PDF • 177KB

Recently, as most have seen by now since I'm late getting this out, CareSource has been denying claims that have a primary unspecified diagnosis code. This was an old rule that was put in place long ago when ICD10 first came out. 

You should never ever use an unspecified diagnosis code as a primary diagnosis. Therapists should use a specific diagnosis code from the evaluation as primary. Here are some examples and exceptions: 

Child evaluated for OT, has fine motor delay, diagnosis of CP from pediatrician: 

Can be listed as: 

1. F82

2. G80.9

   Or 

1. M62.81

2. G80.9

The description of G80.9 is: 

Cerebral palsy, unspecified

The key word here being unspecified. 

Here's another example:

Child is evaluated for speech. Therapist states in evaluation it's a delay.  The diagnosis needs to be specific to be primary: 

1. F80.0

   Or

2. F80.2

Can't use F80.9 because this code states: 

Developmental disorder of speech and language, unspecified

Can't use R62.50 because: 

Unspecified lack of expected normal physiological development in childhood

But could use: 

R62.0 

Delayed milestone in childhood

I've heard feedback from therapists stating, we have to use what the dr puts on the Rx. WRONG. 

The dr is sending the child to you to get a diagnosis. You're performing an evaluation to determine a diagnosis. The dr is signing off on your plan of care that states what you're saying the diagnosis is.  Dr offices simply put down whatever generic diagnosis code on purpose to fulfill the need of having something until it's determined by the evaluation. 

On other news with Caresource, as of February 1st, they will be reducing payment for multiple therapies being seen the same day just like Peachstate. With that being said, let me remind everyone that it is important for providers to complain to DCH when there is a problem with a CMO so that it's recorded for the purpose of contract renewals. 

Georgia Manuals Updates and CMO auth rules

The January 2026 manuals for Georgia Medicaid published some new details that needs to be noted.

Children's Intervention Services (CIS) had clarity added about a prescription needed for an evaluation:

Therapy evaluations including physical therapy, occupational therapy, and speech-language pathology evaluations do not require a referral or separate prescription from a physician in order to be initiated or performed. Licensed therapy providers may independently perform evaluations consistent with their professional scope of practice and applicable state licensure regulations. Therapy services will require a signed POC. (Rev. 01/2026)

There's been a lot of discussion about this topic in compared to Babies Can't Wait/Early Intervention as to getting the patient started with services to meet IFSP deadlines and evaluations.

CMO authorizations often have different rules. Currently (and yes this could change tomorrow):

• You can request an auth for a patient for 1 month with an unsigned Plan of Care, RX from pediatrician, and one of the following: IFSP/IEP/Attestation.

• You can request up to 1 month of services after an IFSP or IEP ends to continue services if the Plan of Care continues past the end date to enable the transition. Example: POC range is 6/1/25-12/1/25. IFSP range is 4/30/25-10/30/2025. The authorization can be requested as 6/1/2025-11/30/2025.

• If you have a new patient who is transitioning from another provider who performed an evaluation within the last 6 months but you want to see the patient before writing your Plan of Care and goals, you can submit an auth request with the Rx, previous evaluation report, letter of change request from parent, IFSP/IEP/Attestation to state you need 1-2 visits to work with the patient to develop your own POC.

  
  

ABA had lots of changes as we expected from announcements made at the November Medicaid conference. Newest manual reflects a template to follow for Plans of Care, along with a new detailed cover sheet for authorizations. Make sure you review the template before submitting a new authorization, as it could cause rejections on a long awaited auth. Changes were also made so that authorizations can be requested 90 days in advance, but make sure you have an updated evaluation within 2 months of the request before submitting.

Lastly, I'm often asked about eligibility and how it effects Medicaid members:

 Members who are terminated and later reinstated with a retroactive eligibility date do NOT qualify for retroactive PAs. Members who are approved for Katie Beckett with a retroactive eligibility date do NOT qualify for a retroactive PA.