---
title: Amerigroup Georgia ABA coverage (GA Medicaid CMO).
url: "https://carelu.com/payers/amerigroup-georgia"
markdown_url: "https://carelu.com/payers/amerigroup-georgia.md"
state: GA (Georgia)
payer: Amerigroup (GA Medicaid CMO)
kind: Medicaid managed care plan (MCO)
parent_program: Georgia Medicaid
description: "How Amerigroup administers ABA for Georgia Medicaid — the CG-BEH-02 adaptive behavioral treatment guideline aligned to the DCH ASD manual, with prior authorization and medical-necessity review."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Amerigroup Georgia ABA coverage (GA Medicaid CMO).

_Payer Guide · Amerigroup (GA) · Last updated September 2026 · 3 primary sources_

> CG-BEH-02 adaptive behavioral treatment; verify current version.

Amerigroup is a Georgia Medicaid CMO that administers ABA under its Adaptive Behavioral Treatment for ASD guideline (CG-BEH-02), aligned to the Georgia DCH ASD manual. Its published guideline has an older revision date, so verifying the current version on the Amerigroup provider portal is especially important here.

This plan administers the **Georgia Medicaid** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Georgia Medicaid guide](https://carelu.com/payers/georgia-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — CG-BEH-02 medical-necessity review [1][2]
- **Prior auth for treatment**: Required — CG-BEH-02 medical-necessity review [1][2]
- **Autism diagnosis required?**: Yes — DSM-5 ASD per the DCH ASD manual [1][2]

## At a glance

- **Plan type:** Georgia Medicaid CMO (managed care)
- **Guideline:** CG-BEH-02 (Adaptive Behavioral Treatment for ASD)
- **Aligned to:** Georgia DCH Part II ASD manual
- **Prior auth:** Required; medical-necessity review
- **Caution:** Published guideline dated 2017/2018 — verify current version
- **Note:** Amerigroup's Georgia CMO status was affected by the 2024 rebid
- **Diagnosis recency:** Eval within 5 years (DCH-aligned criteria)

## How Amerigroup administers the benefit

Amerigroup covers ABA under CG-BEH-02, its adaptive behavioral treatment guideline, aligned to the Georgia DCH ASD manual and subject to prior authorization and medical-necessity review. Because the published version is dated 2017/2018 and likely superseded, treat the linked guideline as a starting point and confirm the current requirements on the Amerigroup provider portal before relying on any specific rule. [1]

## Intake gates

The questions that decide whether a family can start with Amerigroup (GA Medicaid CMO), and what they have to bring.

- **Age limit**: 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.
- **Who may diagnose**: 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]
- **Referral required?**: 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]
- **Telehealth**: 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.
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: "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]

## Delivery and billing rules

Coverage decides whether Amerigroup (GA Medicaid CMO) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: 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.
- **Daily limits / MUEs**: 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]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.

## What intake should collect for Amerigroup (GA Medicaid CMO)

- **Amerigroup member ID:** Confirm the plan and current CMO status at intake.
- **DSM-5 ASD diagnosis:** Per the DCH manual criteria the guideline aligns to.
- **Medical-necessity documentation:** Required for the prior-authorization request.
- **Plan of Care:** Measurable, baseline-anchored goals consistent with the DCH manual.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Amerigroup (GA Medicaid CMO) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00025 — pVerify lists a generic "00025 AMERIGROUP" (Elig: Y) plus a separate GA-inclusive entry "00706 AMERIGROUP (IA,DC,MD,FL,GA,WA,TN,TX,NM)" flagged Elig/Claim: No in pVerify's own table — confirm which code pVerify actually routes GA eligibility checks through before automating on 00025.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required | 32 units/day per day (inferred) | Inferred: GA DCH in-clinic (U6) / out-of-clinic (U7) / telehealth (POS 02 or 10, GT) — not confirmed in Amerigroup’s own guideline | Inferred — GA DCH mechanics (GT modifier, POS 02/10); not confirmed in Amerigroup's own guideline. | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth |
| 97152 | Yes | Required | 16 units/day per day (inferred) | Inferred: GA DCH in-clinic (U6) / out-of-clinic (U7) / telehealth (POS 02 or 10, GT) — not confirmed in Amerigroup’s own guideline | Inferred — GA DCH mechanics (GT modifier, POS 02/10); not confirmed in Amerigroup's own guideline. | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth |
| 97153 | Yes | Required | 32 units/day per day (inferred) | Inferred: GA DCH in-clinic (U6) / out-of-clinic (U7) / telehealth (POS 02 or 10, GT) — not confirmed in Amerigroup’s own guideline | Inferred — GA DCH mechanics (GT modifier, POS 02/10); not confirmed in Amerigroup's own guideline. | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth |
| 97154 | Yes | Required | 18 units/day per day (inferred) | Inferred: GA DCH in-clinic (U6) / out-of-clinic (U7) / telehealth (POS 02 or 10, GT) — not confirmed in Amerigroup’s own guideline | Inferred — GA DCH mechanics (GT modifier, POS 02/10); not confirmed in Amerigroup's own guideline. | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth |
| 97155 | Yes | Required | 24 units/day per day (inferred) | Inferred: GA DCH in-clinic (U6) / out-of-clinic (U7) / telehealth (POS 02 or 10, GT) — not confirmed in Amerigroup’s own guideline | Inferred — GA DCH mechanics (GT modifier, POS 02/10); not confirmed in Amerigroup's own guideline. | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth |
| 97156 | Yes | Required | 16 units/day per day (inferred) | Inferred: GA DCH in-clinic (U6) / out-of-clinic (U7) / telehealth (POS 02 or 10, GT) — not confirmed in Amerigroup’s own guideline | Inferred — GA DCH mechanics (GT modifier, POS 02/10); not confirmed in Amerigroup's own guideline. | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth |
| 97157 | Yes | Required | 16 units/day per day (inferred) | Inferred: GA DCH in-clinic (U6) / out-of-clinic (U7) / telehealth (POS 02 or 10, GT) — not confirmed in Amerigroup’s own guideline | Inferred — GA DCH mechanics (GT modifier, POS 02/10); not confirmed in Amerigroup's own guideline. | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth |
| 97158 | Yes | Required | 16 units/day per day (inferred) | Inferred: GA DCH in-clinic (U6) / out-of-clinic (U7) / telehealth (POS 02 or 10, GT) — not confirmed in Amerigroup’s own guideline | Inferred — GA DCH mechanics (GT modifier, POS 02/10); not confirmed in Amerigroup's own guideline. | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth |
| 0362T | Yes | Required | 16 units/day per day (inferred) | Inferred: GA DCH in-clinic (U6) / out-of-clinic (U7) / telehealth (POS 02 or 10, GT) — not confirmed in Amerigroup’s own guideline | Inferred — GA DCH mechanics (GT modifier, POS 02/10); not confirmed in Amerigroup's own guideline. | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth |
| 0373T | Yes | Required | 32 units/day per day (inferred) | Inferred: GA DCH in-clinic (U6) / out-of-clinic (U7) / telehealth (POS 02 or 10, GT) — not confirmed in Amerigroup’s own guideline | Inferred — GA DCH mechanics (GT modifier, POS 02/10); not confirmed in Amerigroup's own guideline. | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Verify via: Amerigroup Georgia provider portal / current UM guideline — the published CG-BEH-02 (2017/2018) predates 97151–97158 and contains no code-level billing detail; every field on this entry is inferred from the statewide DCH/CMS pattern, not confirmed against Amerigroup's own current criteria.

### Contacts

- **Provider services phone:** 1-800-454-3730
- **Hours:** Monday–Friday, 7 a.m.–7 p.m.
- **Portal:** [Availity Essentials](https://apps.availity.com/availity/web/public.elegant.login)
- **Fax:** 1-800-964-3627

Questions to ask on a verification call:

- Which pVerify payer ID should we use for Amerigroup GA eligibility checks — the generic 00025, or 00706 (flagged No for eligibility/claims in pVerify's own table)?
- What is Amerigroup GA's correct Availity payer ID — Availity's list resolves 26375 to Amerigroup Fort Worth, TX, not Georgia?
- What Change Healthcare payer ID do you use for Amerigroup GA eligibility checks?
- Does eligibility checking return real-time or batch-only 271 responses?
- Is the ABA cost share a copay or coinsurance, and is it charged per visit or per day?
- Which service-type-code bucket does Amerigroup GA return ABA benefit detail under, and does the deductible or out-of-pocket max apply?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.mmis.georgia.gov/portal/PubAccess.EDI/Companion%20Guides/tabId/45/Default.aspx (accessed 2026-07-23)
- https://provider.amerigroup.com/docs/gpp/GA_CAID_UMGuideline_AdaptiveBehavioralTreatmentAutismSpectrumDisorder.pdf?v=202101081602 (accessed 2026-07-23; source document older than 18 months)
- https://www.mmis.georgia.gov/portal/portals/0/staticcontent/public/all/notices/autism%20spectrum%20disorder%202023%20(002)%2020230209200139.pdf (accessed 2026-07-23; source document older than 18 months)
- https://provider.amerigroup.com/georgia-provider/contact-us (accessed 2026-07-23)

## Common questions

### Does Amerigroup Georgia cover ABA therapy?

Yes — Amerigroup administers the Georgia Medicaid ABA benefit under its CG-BEH-02 adaptive behavioral treatment guideline, aligned to the DCH ASD manual, with prior authorization and medical-necessity review.

### Is Amerigroup's Georgia ABA guideline current?

The publicly available version is dated 2017/2018 and is likely superseded. Verify the current guideline on the Amerigroup provider portal before relying on specific requirements.

## Primary sources

1. [Amerigroup — Adaptive Behavioral Treatment for ASD (CG-BEH-02, GA Medicaid)](https://provider.amerigroup.com/docs/gpp/GA_CAID_UMGuideline_AdaptiveBehavioralTreatmentAutismSpectrumDisorder.pdf?v=202101081602)
2. [GA DCH — Part II ASD Policy Manual](https://medicaid.georgia.gov/document/publication/asd-policy-manual/download)
3. [GA DCH — Part II Policies and Procedures for Telehealth Guidance, version date 10/1/2025 (hosted copy — the medicaid.georgia.gov download link serves a 2020 file and GAMMIS blocks automated access)](https://setrc.us/wp-content/uploads/2025/11/Telehealth-Guidance-Q4-October-2025.pdf)
4. [Amerigroup Georgia Medicaid Provider Manual (GA-AGP-CD-PM-003925-26)](https://provider.amerigroup.com/docs/gpp/GA_CAID_ProviderManual.pdf)
5. [42 CFR 438.210(d) — MCO authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
6. [Georgia SB 80 (2021) — O.C.G.A. 33-46-26, -27, -29, -30 (Ensuring Transparency in Prior Authorization Act)](https://gov.georgia.gov/document/2021-signed-legislation/sb-80/download)
7. [GA DCH — Part I Policies and Procedures for Medicaid/PeachCare for Kids (version date July 1, 2026), 104.3 and 303 (GAMMIS copy retrieved via web.archive.org)](https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Part%201%20Policies%20and%20Procedures%20for%20Medicaid%20PeachCare%20for%20Kids%20Q3%20July%202026%2020260706155614.pdf)
8. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage, Medicaid excepted](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
9. [CHAMPVA Guidebook (updated Jan. 1, 2025) — Other Health Insurance](https://www.va.gov/COMMUNITYCARE/docs/pubfiles/programguides/CHAMPVA-Guide.pdf)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.