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June 20, 2013
The Chapter has learned that Sherwood Clinical will no longer be providing Synagis Services in Georgia. As we understand it, the commercial carriers as well as the CMOs will allow a third party to purchase Synagis and ship it to the physician’s office for administration. However, Medicaid Fee For Service (FFS) does not allow this.
Currently, the only options with FFS are for practices to “buy and bill” or refer to home care. In this scenario, practices have reported that purchasing Synagis would be cost prohibitive given that Medicaid FFS does not cover the full cost of the service. We are not aware of how many newborns leave the hospital assigned to a specific CMO. If newborns are typically enrolled under Medicaid FFS until a plan is selected by the family, this could create an access issue. Additionally, we hear reports that in some of the rural areas there is no home health service available.
Here is a listing of known Synagis Providers
It would be helpful to hear from Chapter members as to how critical this issue is for your patients. Please contact Fozia Eskew at the Chapter office at 404-881-5074 or This email address is being protected from spambots. You need JavaScript enabled to view it. if you have any questions or have additional information on this issue.
Click Here for Information on Peach Care for Kids
Reimbursement NOW available Developmental Screens in Health Check - In order to be reimbursed for the developmental screenings required by Georgia Medicaid at the 9, 18, and 30 months visits, members are to bill code 96110 with the EP modifier and the appropriate ICD-9 diagnosis code - V20.2 or V70.3 - in order to receive reimbursement for the Developmental Screening. Only one (1) Developmental Screening will be reimbursed at each of these intervals. The reimbursement rate is $11.74.
A few of the tools that meet the Medicaid requirement for this code include the Ages & Stages Questionnaire (ASQ II and ASQ III), Parents Evaluation of Developmental Status (PEDS), Child Development Inventory (CDI) - 18 months to 6 years, and the Infant Development Inventory – Birth to 18 months. The child’s medical record should include a note indicating the date on which the test was performed, the standardized tool used, and the screening result result/score.
If the child is not seen at the 9, 18, or 30 month visit, a developmental screening should be performed during the Catch-Up visit for the missed periodic visit. This Catch-Up Developmental Screening should be billed, using the EP and the Medicaid Program specific “HA” modifiers along with the 96110 CPT code and the appropriate ICD-9 codes. Only one (1) Catch-Up Developmental Screening during any one (1) Catch-Up interval is allowed.
Proposed Medicaid Fee Reductions not implemented: In August 2009 meeting, the Georgia Dept. of Community Health board approved a proposal that would reduce payments to the CMOs by 1.86% for Fiscal Year 2011. This proposal was rescinded during the June 2011 Board meeting
CMO State-wide Expansion - Effective January 1, 2012, the Department of Community Health (DCH) announced the network expansion of Peach State Health Plan into the North, East and Southeast regions of Georgia. Also, effective February 1, 2012, the DCH announced the network expansion of Amerigroup Community Care into the Central and Southwest regions of Georgia. Both health plans now operate state-wide.
Georgia Health Partnership – Fee-for-Service (FFS) Medicaid - Hewlett Packard Enterprise Services (HP) is an electronic healthcare administrative system. Effective 11/1/2011, HP became the DCHs third party administrator for Georgia Medicaid and PeachCare for Kids that are excluded from the Georgia Families (GF) program.
Web Portal Trainings - HP offers provider trainings via the GHP web portal. Courses include, but are not limited to, Crossover, Understanding Provider Enrollment and Easy use of the GHP Web Portal. Click here to visit the GHP Web Portal to access these trainings. In addition, HP field representatives are available to assist you. If you would like to schedule a meeting with your field representative, please call the HP call center at center at (800) 766-4456.
The Medicaid Managed Care Act: This piece of legislation (also known as HB1234), was passed during the 2008 Georgia Legislative Session and signed into law by the Governor. A few of the areas it focuses on include claim submissions, 72 hour eligibility rule, reimbursement of emergency care, and dental services provided by the Care Management Organizations (CMOs). Click here for full details.
Medicaid Redesign update - DCH retained Navigant Consulting to conduct a comprehensive assessment and recommend a redesign of Georgia's Medicaid Program and Children's Health Insurance Program. The Assessment Phase has been completed and the Strategy Report is available to public review on the DCH website. The department as created several task forces to assist in the recommendation process for redesign. The Chapter currently serves on the Task forces for Families and Children.
Below is the currently time line for redesign:
Recommendation – Underway
Procurement – Later in 2012, 2013
Implementation – Planned for Early 2014
ICD-10/5010 Conversion – HP Enterprise Services will accept and return HIPAA transactions in both versions 4010A1 and 5010. However, as of July 1, 2012, version 4010A1 will no longer be an accepted format for HIPAA transactions. On February 16, 2012 CMS announced the delay from the original 10/1/2013 date for State implementation of the ICD-10 code sets. No replacement date was made; however, DCH is moving forward with their review and comparison of codes sets as well as system testing for readiness.
Termination of Georgia Better Health Care (GBHC) - The Georgia Better Health Care (GBHC) Program is the Primary Care Case Management (PCCM) program for the State of Georgia. The GBHC program was reviewed by the DCH and the Centers for Medicare and Medicaid Services and based on this review, the DCH terminated the program effective September 30, 2011. The impact of this change was felt by GBHC enrolled physicians because they no longer received the $2.00 per member per month additional payment to coordinate care for this group of Medicaid members.
Coordination of Benefits: Georgia Medicaid Fee for Service (FFS) and the CMOs are referred to as "payors of last resort" under federal law. This means that if there is other third party or private insurance available, it must cover the child's medical care. The exceptions to this rule are preventive and pediatric services including Health Check and non-institutionalized pregnancy related services. Refer to the plan's Coordination of Benefits section for details on claims submission. However, if you have billed Peach State and Amerigroup for a sick visit and your patient was later shown to have third party coverage, these plans will contact the third party plan to obtain reimbursement. If you have billed WellCare for a sick visit and your patient is later shown to have third party coverage, WellCare will recoup payment from your office and you will need to bill your patient's third party payor.
If you are a Chapter member and have a concern regarding one of the three, please email your question to This email address is being protected from spambots. You need JavaScript enabled to view it. . While we do not have a staffer at the Chapter office dedicated solely to helping with Medicaid issues, we do have some of your physician leaders who can answer these questions and Chapter staff that can assist in certain areas, especially on immunizations or Health Check questions.
Centene Corporation DBA Peach State Health Plan
With corporate headquarters in St. Louis, they currently operate in Indiana, Kansas, Missouri, New Jersey, Ohio, Texas and Wisconsin. To identify the local provider representative for your area, contact Provider Services at 1-866-874-0633.
Based in Virginia Beach, Virginia they operate as a Medicaid only managed care organization. They currently operate in the District of Columbia, Florida, Illinois, Maryland, New Jersey, New York and Texas. To identify the local provider representative for your area, contact Provider Services at 1-800-454-3730.
They are a provider of only government sponsored health products. They are based in Tampa, Florida and currently operate in Connecticut, Illinois, Indiana, Florida, Louisiana and New York. To identify the local provider representative for your area, contact Provider Services at 1-866-231-1821.
CMO Credentialing Escalation Process:
In the even you are experiencing credentialing concerns with the CMO, you can utilize the below escalation process. Please remember this should not be your first line of defense. You should always contact your CMOs area Field Representative first.
Checking Medicaid CMO Eligibility:
With the implementation of HB 1234 in 2008, there have been some changes to the way you verify member eligibility. Previously, you would go to the CMOs websites to determine eligibility by plan affiliation; however, due to the bill the only acceptable verification of plan affiliation for a member is via the GHP web portal. You may notice that all the CMOs have a link to the GHP web port for plan affiliation verification. You may still utilize the CMO eligibility verification for PCP assignment.
Recoupment of Claims by CMOs:
Pediatricians have reported experiencing recoupment from CMOs, in some cases up to 12 months after the date of services. This may occur for a number of reasons, but the most common is the CMO that paid the claim was not the responsible payor. One of two things may occur:
1. The incorrect CMO is listed on either the GHP web portal or the CMO portal. DCH has worked diligently to minimize this problem and you should seldom see this occurrence. The CMOs have agreed to waive timely filing in these cases and are working together to ensure proper payment to providers.
2. The member has primary insurance that was not discovered until after the date of service. In these instances where the CMO is unaware of a members other insurance at the date of service and discovers other insurance after services have been rendered, DCH has instructed the CMOs to cease and decease recoupment from the provider and utilize pay and chase methods with the primary insurance. This change in policy went into effect September 2008. If you have recoupment prior to September 2008 relating to Third Party Liability, you are encouraged to appeal the claims with the primary insurance. If the denial is upheld you can utilize the individual CMOs appeals process.
Who is eligible for the Georgia Families Managed Care Program?
Individuals who are eligible to enroll in Georgia Families include low-income families, children, and pregnant women, women eligible for Medicaid due to cervical cancer and PeachCare for Kids to managed care. Aged, Blind and Disabled (ABD) population and Foster Care children are not included in the managed care program at this time.
How can your patients can enroll in Georgia Families?
Maximus, the enrollment broker for GA Families, works with Medicaid members who are eligible to participate in the GF program. Members are encouraged to do the following to enroll:
1. By calling 1-888-GA-ENROLL (1-888-423-6765) or click here for the on line enrollment process.
2. By completing an enrollment packet and mailing it to GF
3. Attending an assisted enrollment session
Once a member has enrolled into a plan, they will have 90 calendar days to change their health plan or PCP. After the 90-day period, they will not be able to make any changes to their health plan affiliation without cause until the open enrollment period begins the following year.
To assist you and your patient in the enrollment process, there are a few thing you should know:
• Maximus has also developed a brochure and CMO comparison sheet that you can download from their website (https:www.georgia-families.com) for distribution to your patients in the office.
• Providers can tell their patients which plans(s) they are participating with, but they cannot advise their patients’ which plan to choose. The patients need to chose a plan based on their own decision making process.
Please be reminded that CMO Medicaid members have the option during their open enrollment period (once per year) to change their CMO and PCP assignment. Open enrollment is continuous, based on the individual member’s enrollment date. Members will receive a letter from Georgia Families 30 days prior to their enrollment anniversary date. If the member does not make a choice during the 30-day window they will remain in their CMO.
The Medicaid Health Check (formerly EPSDT) program is Georgia’s well child preventive health care program for Medicaid-eligible children birth to 21 years of age and PeachCare-eligible children birth to 18 years of age. It is the Early and Periodic Screening, EPS component of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. Georgia Medicaid provides and reimburses the Diagnostic and Treatment aspect of EPSDT services under other programs (such as Laboratory, Children Intervention Services (CIS), Physicians, Hospitals, Home Health, etc).
Reviewing your Health Check Record
Although Health Check Record Reviews are currently not available as a service through the Chapter, it is important to periodically review your charts for Health Check accuracy. The goal of the Health Check program is to make certain a child’s health needs are met through initial and periodic exams and evaluations, so that health problems are found, diagnosed and treated early.
Billing Tips for Health Check
The Health Check manual is updated quarterly in January, April, July and October and can be downloaded off the Medicaid web portal under the tab Provider Manuals. The following are tips to guide you when billing for Health Check Services with FFS.
1. Use the AAP/Bright Futures Periodicity Schedule.
2. Use the HIPAA compliant CPT codes located in the Health Check Provider manual (Appendix C)
3. Use the HIPAA compliant diagnosis codes located in the Health Check Provider manual (Appendix C)
4. Continue using the appropriate EP and TJ modifiers. EP identifies the claims as Health Check and TJ identifies the patient as a Foster Care child
5. Use the EP modifier on all immunizations
6. Continue using the HIPAA referral codes listed below and in the Health Check manual (Appendix J)
7. Pap smears are available on the same date as an abnormal Health Check with procedure codes 88141-88182 and diagnosis codes V76.2 or V76.49
Health Check Referral Codes- The following are the acronyms and descriptions of the Health Check referral codes. Be sure to indicate “N’ for no or “Y” for yes in box 19 of the CMS 1500 form and then document one of the following:
1. AV- Available; Not used (patient refused)
2. NU- Not used
3. S2- Under Treatment
4. ST- New Services Requested
Click here to visit the online center for your practice staff can to enroll in Medicaid and PeachCare. You can begin the process by accessing the Provider Enrollment Tab, then the click the Enrollment Wizard link. Once you've completed the online application, you will receive a confirmation number. Supporting documentation can be uploaded to the portal during the enrollment process. Each provider in your practice must enroll separately. The effective date of enrollment will be the first day of the month in which the completed application is received by GHP or the effective date of any required license, whichever is later. When adding an additional location, completing an entire application is not necessary. An abbreviated coversheet entitled "Additional Location for Individual Practitioner" is available.
A provider can be added to an existing group as long as they have a Georgia Medicaid number. However, an "Additional Location (DMA-005)" form will need to be completed. Be sure to write the payee number on the cover sheet. This will help link the new provider number to the group and help you avoid the need for and FTE or W9.
Also, if you are opening your own practice, you can continue to provide services to Georgia Medicaid children as long as you already have a Georgia Medicaid number. All that will be needed is for you to complete an "Additional Location (DMA-005)" form. A power of attorney is also needed.
When changing information, such as telephone numbers, EPO status, etc. you will need to complete a "Change of Information Form.”
Enrolling into Care Management Organizations (CMO) - Each CMO has their own criteria for contracting and credentialing with their plan. You can go to their websites for further information on contracting with their plan. Remember…a Medicaid ID number is required to participate in the CMOs network. Medicaid ID numbers are location specific. You can obtain a Medicaid ID number by going to the GHP web portal. Once you’ve completed the application you will receive a temporary Medicaid ID number. You can simultaneously begin the credentialing process with the CMOs using the temporary Medicaid ID number. Credentialing with the CMOs can take up to 180 days, but typically only take 60 days.
Planning for Health Babies (P4HB) - Planning for Healthy Babies (P4HB) is a waiver program developed by the DCH with the goal of reducing the number of low birth weight (LBW) and very low birth weight (VLBW) births in Georgia. Effective January 1, 2011, this two year program began providing Family Planning, Inter-Pregnancy Care (IPC) and Recourse Mother (case management) services to members 18 through 44, who would otherwise not be eligible for Medicaid.
Services include:
If you have a patient who is a Low Birth Weight or Very Low Birth Weight, you can refer the mother to www.P4HB.org for further details on how to apply for this program.
American Academy of Pediatrics
Georgia Chapter
404-881-5020
1330 West Peachtree Street NW, Suite 500
Atlanta, Georgia 30309
