Amerigroup Georgia ABA coverage (GA Medicaid CMO).

Follows the Georgia Medicaid rule: Adaptive Behavior Services are an EPSDT benefit and “Autism Spectrum Services are for individuals under the age of 21.” Amerigroup’s UM Guideline CG-BEH-02 publishes no age criterion of its own — it is a medical-necessity guideline keyed to whether “a state mandate requires or a benefit plan explicitly provides coverage for ABT,” not an eligibility document.^[2][1]

Ask the plan: Note the vintage: the posted CG-BEH-02 is dated June 2018 (GAPEC-2437-18) and Amerigroup GA is operating under a DCH contract extension through 6/30/2027 — confirm the current guideline on the Amerigroup/Wellpoint provider portal.

Scope-of-practice based and deliberately broad: “a diagnosis of ASD has been made by a licensed medical professional or other qualified health care professional as is consistent with state licensing requirements.” The guideline separately requires documentation “that ABT services will be delivered by an appropriate provider who is licensed or certified according to applicable state laws and benefit plan requirements.” The Georgia floor is narrower and governs for Medicaid members: the diagnosis must be established by a licensed physician or psychologist, or another licensed professional designated by the Medical Composite Board, and made by a practitioner with one year of experience serving individuals with an autism diagnosis.^[1][2]

CG-BEH-02 is a medical-necessity guideline and states no referral gate, so the Georgia Medicaid structure governs: ASD services must be recommended by a licensed physician or other licensed practitioner of the healing arts acting within their scope of practice under state law per 42 CFR 440.130(c); all ABS prior authorizations must be requested by the enrolled QHCP (a licensed physician, psychologist, BCBA-D or BCBA — never a BCaBA or RBT); and the ordering, prescribing or referring practitioner’s NPI must appear on the CMS-1500 in box 17 with the DK, DN or DQ qualifier and be enrolled in Georgia Medicaid, or the claim denies. Assessment and treatment are authorized separately in six-month increments.^[3][2][1]

CG-BEH-02 contains no telehealth provision, so the Georgia Medicaid floor governs: under the DCH Part II Telehealth Guidance (version date 10/1/2025), “practitioners of ASD services can use telehealth to assess, diagnose and provide therapies to patients,” and the guidance publishes the billable ABS telehealth codes — 97151–97158, 0362T and 0373T in 15-minute units with the GT modifier plus the U1–U5 practitioner-level modifier, on POS 02 (member outside the home) or POS 10 (member at home). Prior authorization applies to telehealth ABS exactly as in person.^[3][1]

Ask the plan: Amerigroup/Wellpoint Georgia provider services for any plan-level restriction the posted 2018 guideline would not show.

Amerigroup's Georgia Medicaid manual: "Amerigroup will decide on pre-service nonurgent care services within three business days from when we receive the request for service," and providers are notified through Availity or the MMIS portal in the same three business days. It may add 14 calendar days if the member or provider asks, or Amerigroup justifies needing more information to DCH. Expedited requests are decided "within 24 clock hours from when we receive the request for service," with notice "no later than 72 hours from the receipt of the request." The manual publishes no reauthorization lead time for ABA. Its 30-days-before-expiry renewal rule covers medical injectable and pharmacy PAs only. The ABA guideline expects the treatment plan to be updated and resubmitted "in general, every 6 months."^[4][1][5][6]

"Amerigroup agrees that the Medicaid program will be the payer of last resort when third-party resources are available." When it knows of other coverage before paying, Amerigroup will reject the claim and redirect "the provider to bill the appropriate insurance carrier." When it learns later, it recovers after payment. "State-specific guidelines will be followed when Coordination of Benefits (COB) procedures are necessary." For COB, "the time frames for filing a claim will begin on the date that the third party documents resolution of the claim." The manual publishes no pay-and-chase exception. Get Medicaid's own PA even when Medicaid is secondary. DCH's Part I manual: "Regardless of whether or not the primary plan has made any payment toward a service, when billing the secondary claim to Medicaid, you must follow the Medicaid policies and procedures for that particular Category of Service, including adherence to all policies/guidelines for pre- certification and pre-authorizations of services." TRICARE pays only after other coverage "except in the case of a plan administered under title XIX" (Medicaid), so TRICARE goes before Georgia Medicaid. CHAMPVA is the reverse: "If you are eligible under Medicaid, CHAMPVA will pay first."^[4][7][8][9]

Not published. CG-BEH-02 requires a diagnosis of ASD and measurable goals “based on standardized assessments,” with “baseline measurements, progress to date and anticipated timeline for achievement based on both the initial assessment and subsequent interim assessments over the duration of the intervention” — but it names no recency window on the diagnostic evaluation and no re-diagnosis trigger. The Georgia floor is the DCH rule that an outside assessment is accepted for a treatment PA only if “conducted/dated no more than six (6) months prior to the treatment PA request submission.”^[1][2]

Blocked on: Amerigroup/Wellpoint Georgia provider services for the current guideline; the CMOs that do publish a window (CareSource MCD-MM-0212 and Peach State GA.CP.BH.504) both use five years from the initial diagnosis as the re-evaluation trigger.

CG-BEH-02 names no instrument. It requires that “assessments of motor, language, social, and adaptive functions have been completed” and that treatment-plan goals be “in objective and measurable terms based on standardized assessments,” and defines assessment instruments generically as “specialized and standardized diagnostic test used to evaluate an individual’s performance.” Which instruments qualify is left open.^[1]

Blocked on: Amerigroup/Wellpoint Georgia provider services and the current GA DCH ASD manual inside GAMMIS; Peach State GA.CP.BH.504 publishes the operative Georgia two-tool list (one primary clinician tool plus one caregiver tool) openly.

Amerigroup publishes a supervision ceiling rather than a floor: “Up to two (2) hours of protocol modification will be covered for every ten (10) hours of direct ABT therapy. Any greater frequency of protocol modification will require written documentation demonstrating the need for additional protocol modification.” In practice that is a 20% cap on 97155 against 97153 before extra justification is required. Note the vintage — UM Guideline CG-BEH-02 carries a current effective date of 9/27/2017 and a last review date of 8/3/2017.^[1]

Ask the plan: Confirm CG-BEH-02 is still the operative Georgia guideline — Amerigroup GA is operating under a DCH contract extension through 6/30/2027 and the posted guideline is dated 2017.

Amerigroup gates by the week, not the day. “The total hours of ABT requested should be comprised of fewer than 40 hours per week” — more than 40 requires documentation of why, because “ABT services for more than 40 hours per week have not been shown to be more effective.” Group adaptive behavior treatment and social-skills group hours count inside that 40. Exposure adaptive behavior treatment and exposure treatment with protocol modification (0362T/0373T) “should be comprised of fewer than 10 hours per week.” No per-code per-day unit ceiling is published.^[1]

Not addressed. CG-BEH-02 is a medical-necessity guideline, not a reimbursement policy, and contains no same-clock-time rule for 97153 with 97155.^[1]

Ask the plan: Amerigroup/Wellpoint Georgia provider services, and the Georgia fee schedule inside GAMMIS.

Not addressed. The guideline sets documentation expectations for authorization (clinical summaries justifying hours per behavioral target, progress measured against baseline) but no session-note signature rule.^[1]

Blocked on: Amerigroup GA provider manual; Georgia DCH’s standard — the writer signs and dates, real time, no back-dating — is the applicable floor.