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.

Group Georgia Medicaid applications, new CMOs for Georgia and Amerigroup credit cards

It's the new year so time for new paperwork. Here's a reminder of all the things you might have forgotten about for the new year:

• New intake forms - these can be a shorten version of new paperwork, as long as you have info of agreeing they're financially responsible, HIPAA rules informed, insurance ok to bill, address/insurance info, signature of patient or parent/guardian

• Need a copy of their photo id and insurance card. It's a legal requirement to have these on file. 

• Good faith estimate form - a must for patients who are private pay. I recommend everyone signing one actually. 

• Remember, new year, new benefits for most. Insurance customer support lines are open longer now to get coverage info to those who need it. 

• Review your private pay rates, adjust other paperwork now. Remember for pediatric clinics, you should base the lowest income at Medicaid rates. 

  
  

Remember when billing claims you do not cross years. In other words, if you send claims out together, don't send 2025 and 2026 on the same claim. Send them individually if your software doesn't already separate it for you.

Group Medicaid applications have been delayed. You can still file the application now, but they've delayed the deadline to later in 2026 to have more training courses online. You must be logged into your payee id when you do so on GAMMIS. If you do not have that login, call the Medicaid portal support line (different than their main line) at 877-261-8785 to ask for a pin reset (option 1). They will mail this to you, will take 7-10 business days. When you first register your group (remember this is for providers with 2 or more providers currently practicing under a tax id), you must list all the providers currently active on the application. You will need a copy of your corporation paperwork and county/city license as well to upload. 

Amerigroup will start sending credit card payments instead of checks mid January: 

https://providernews.amerigroup.com/ga/articles/electronic-payments-starting-in-mid-january-2026-23872

IF YOU DO NOT GET DIRECT DEPOSIT WITH AMERIGROUP, SIGN UP ASAP TO FIX THIS.

Enrolling on enrollsafe will get you direct deposit for AG and BCBS as well. Here's the link to enrollsafe: 

https://enrollsafe.payeehub.org/

Here are other ways to sign up for eft for certain insurances: 

Aetna: https://payerenrollservices.com/

Peachstate: https://www.payspanhealth.com/nps/login.aspx

UHC: https://myservices.optumhealthpaymentservices.com/registrationSignIn.do

Cigna: (must register under their provider portal) https://cignaforhcp.cigna.com/

I'm often asked about the updates Availity threatens when you don't update your info there under PDM (provider data management). Here's what happens if it's not updated (per BCBS website) https://providernews.anthem.com/georgia/articles/reminder-provider-data-attestation-24376

Why is updating and attesting to my data important?

Our members use Find Care to make informed decisions about their healthcare and find quality doctors and hospitals. Keeping your data up to date ensures members have access to you when they need it the most.

Failure to complete the 90‑day attestation requirement puts your organization at risk of being classified as non‑compliant with the health plan’s policies and procedures and may result in removal from the online provider directory.

Lastly, I know a lot of talk is going on with the new CMOs. Looks like AG and PSHP lost their protest (of course), but I don't expect to see changes til later this year. When Caresource was added, the state gave us an announcement of 6 months notice, gave patients 2 months to change their insurance to a new plan, and if they didn't like that plan, still gave another 30 days to change after the deadline. So we will be given time to get things sorted when they're ready to move forward. New CMOs are Caresource, Humana, Molina and UHC.

Thanks for all you guys do for your patients and community!

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.