Caresource Georgia denials - appealing

With the recent experience of Caresource's denials for "no authorization or authorization units exceeded", this is the process on how to appeal these claims: 

Caresource requires that each appeal contain all documentation: 

https://www.caresource.com/ga/providers/tools-resources/health-partner-policies/administrative-policies/medicaid/

At this link, you can click on M for 

• Medical Record Documentation Standards for Practitioners

to find the documentation required for appeals....

Please note: 

All documentation when appealing must contain each page listing the members name, dos, page number (personally I'm going to add claim number too)

Documentation should be: 

Note from dos

Current evaluation, POC signed by md and Rx 

Proof of authorization

To submit appeal on the claim. Search for the claim on their web portal. Then find the appeal tab: 

Appeals should take 14 business days per call to customer service as of 8/18/25

If you had already appealed a claim but it was dismissed, you can appeal again. Only a second level appeal need to be performed if it's denied. Do not do a dispute unless there is a payment made on a claim.

My opinion: This isn't a glitch, this is how they plan on conducting medical review from now on. 

Creating a group enrollment application with Georgia Medicaid

Georgia Medicaid will require another application for groups (tax id with 2 or more providers) by 12/31/2025. 

Medicaid is changing the filing process for group professional claims to relate to the NPI. 

"The Payee's NPI is not collected during a rendering provider’s enrollment. By enrolling Group/Billing Providers, the billing provider’s NPI and Payee will be collected, and rendering providers will be affiliated to their Group/Billing providers." 

Anyone who files professional claims will need to file a group enrollment. Therapists, physicians, psychologists, ABA, etc. 

A group enrollment application must be created while logged under the payee login. 

For each application, you'll need a copy of your city or county business license and a copy of your current corporation paperwork: 

To start your application: 

Login to your payee account on GAMMIS. If you do not have a login for your payee number, call Medicaid here:  877-261-8785.

Don't know your payee number? Look at your remittance advice on GAMMIS on the top right of the report to see the number there: 

You can find your remittance advice under any provider who has had recent Georgia Medicaid claims paid. 

Once logged into the payee login, go to:

Provider Enrollment, enrollment wizard

Select Group/Billing and select Provider Type*:

When you get to the selection of Provider Specialty, make sure you add for each type of service you offer in your group:

You need to do an application for each location. So once you complete your first application, return and login to create the second one. 

DCH Q&A here: 

Group_Billing Enrollment FAQ v4 20250717210645.pdf

And a presentation DCH did earlier this year to show you steps on how to apply: 

Enterprise Email Service

Questions or need help? Feel free to contact us!

Caresource of GA authorizations, Peachstate and Medicaid of Georgia manual updates

Lots of changes lately to keep us on our toes....

CareSource will be requiring authorizations starting 7/10/2025 for PT/OT/SLPs again. Most authorizations are returning within 12 hours or less. To follow suit with Medicaid auths, we request the auth through the end of the month the POC expires. Some of these authorizations are being voided on GAMMIS for "auth not necessary".

If you see this, submit the following auth form via fax to obtain an authorization for that patient.

https://www.caresource.com/documents/ga-medical-prior-authorization-request-form.pdf

PSHP has been also processing and paying claims again. There was a brief interruption due to a system update that started around 6/10 and lasted until almost the end of June, rejecting for ordering/prescribing/referring provider missing or incorrect. It's best to resubmit claims back to Peachstate in most software to get them to process IF you don't see the claim pending online. Also make sure to run another A/R report to make sure all claims were processed at the end of this month.

Medicaid manual has been updated on GAMMIS for this quarter. The two changes listed were for clarifying Medicaid's definition of CPT codes 97550 and 96112/96113:

1001.14. Clarification on the use of CPT code 97550 - Use of this code must be documented in the plan of care with specific information on how and why it is medically necessary to provide caregiver training without the member present. CPT code 97550 should not be used for review of goals or review of the latest therapy session. This code should be specific training for a technique, procedure, equipment use, or care and programming for more complicated equipment. This code does not substitute for home program instruction and review. Documentation should reflect separate time and scheduling for this training outside of care of the member. (Rev. 07/2025)

1001.15. Clarification on the use of CPT code 96112 and 96113 – Use of CPT code 96112 goes beyond the scope of a typical evaluation by the individual professional. It includes standardized testing when done in its entirety but should not be used for portions of a standardized test or developmental tests for the purpose of screening only. Portions of a standardized test are allowed for the CIS requirement of standardized testing; however, portions of standardized testing will not be considered adequate to support use of 96112. (Rev. 07/2025) 1001.15.1. CPT code 96113 is an add-on code to allow additional time following the use of CPT code 96112. When requesting, 96113, you must also request 96112 on the same PA and it should be accompanied by significant documentation to support the need for both. (Rev. 07/2025)

Also note that in April 2025 Medicaid changed the timeline for all documentation for Children's Intervention

Maintain written documentation of all services provided to members for a minimum of 10 years after the date of service

Childrens Intervention Services (CIS) - Q3 July 2025 20250616160947.pdf

Medicaid manual for ABA also have several changes this month that should be noted.

Autism Spectrum Disorder - Q3-July 2025 20250630145900.pdf

The cover sheet has been updated that should be used for all authorizations going forward.

Noted changes:

804.11. Behavior reduction line graphs tailored for the school setting, designed to comply with the specifications outlined in Appendix D. As part of the clinical review process, any behavioral interventions implemented in the school setting that were amended or modified during the previous authorization period due to insufficient progress must be clearly identified. These changes should be visually represented using phase change lines within data displays to demonstrate the effectiveness of the revised interventions. This visual documentation supports data-driven decision-making and ensures transparency in treatment adjustments.

803.5. Updated data collected during previous treatment authorizations (if not initial request). For continued treatment authorization (non-initial requests), updated data collected during the previous authorization period must be current and aligned with the most recent behavior assessment. For any new goals that were previously baselined but not yet introduced, probe data must be included. This data should reflect the member’s current performance and must not be more than two months older than the effective date of the requested prior authorization. This ensures that treatment planning is based on timely and relevant information.

804.10. Titration plan that includes a timeline when behavioral conditions qualify the fading out of school services when criteria for progress are established.

804.12. The most recent Individualized Education Plan (IEP), Individualized Family Support Plan (IFSP), and/or 504 plan should be included for members who attend a public school.

When school services are medically necessary, school plans should be accompanied with a treatment plan for services to also occur in either the home and/or clinic setting as treatment in the school setting is limited to the reduction of problem behavior that impede the member’s ability to engage in academic tasks and the teaching of functionally equivalent replacement behaviors. Exceptions to services occurring exclusively in the school environment will be evaluated on an individual basis and must be supported with clinical rationale.

Training of School Personnel: To promote consistent coordination of care, it is strongly encouraged that training of school personnel occurs in the presence of the parent or guardian, either virtually or in person. This collaborative approach ensures alignment across home and school environments. When additional school support is medically necessary, providers may request supplemental units of CPT code 97156. These requests should include clearly defined goals specific to the school setting, with a focus on training related to behavioral intervention procedures and the implementation of appropriate replacement behaviors.

Also remember for authorizations for ABA (from the manual:

Please allow up to 45 calendar days for the PA request to be reviewed and a decision to be rendered. Allow up to 10 calendar days for the reconsideration request to be reviewed and a decision rendered.

Please note that ALL PA’s for ALL Medicaid Members MUST be APPROVED prior to services being rendered. Any services rendered without an APPROVED PA or provided prior to the PA Effective date will not be authorized or eligible for reimbursement. Effective dates on existing PA’s cannot be made retro or backdated under ANY circumstance or for ANY reason. 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.

Providers may set the PA effective date for up to 30 days prior to the submission date.