CareSource is one of the Georgia Medicaid care management organizations (CMOs) that administers the ABA benefit. Its ABA policy (MCD-MM-0212) is aligned to the Georgia DCH Part II ASD manual, but CareSource layers its own utilization-management process on top — so if a family carries CareSource, this is the guide that governs their authorization.
CareSource performs in-house prior authorization and medical review using the Georgia ASD manual plus MCG Health criteria, and requires signed treatment documentation to be submitted prior to claims submission. Because it aligns to the DCH manual, the underlying clinical rules mirror Georgia Medicaid — but the submission path, forms, and timelines are CareSource's own.[1]
Effective May 11, 2026, CareSource pays 80% of the Georgia Medicaid fee schedule for covered services — a material change for practices modeling CareSource revenue. It does not change coverage, but it changes the economics of every CareSource authorization.[1]
The questions that decide whether a family can start with CareSource (Georgia Medicaid CMO), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21, with a participation condition attached: “member is under the age of 21 and must be able to participate in sessions.” CareSource adds that parents and caregivers “must be able to participate in ABA therapy and have the ability to implement ABA techniques in the home environment. If unwilling or unable, consideration will be given to other modalities of treatment” — so caregiver availability is an eligibility question at intake, not just a clinical preference.[1][2]
No fixed expiry, but three named triggers force a diagnostic re-evaluation reconfirming the diagnosis — “the diagnosis of ASD is provisional,” “no formal neuropsychological evaluation was completed,” or “the initial diagnosis is at least 5 years old with no evidence of ongoing assessment and treatment” — and that re-evaluation “must include, at a minimum, 1 clinician observational assessment (school psychoeducation assessments are not acceptable).” On the assessment side the clock is tight: the behavioral assessment PA “may be requested in 3-month increments and completed one time during the 6-month treatment authorization period no more than 2 months prior to the effective date of the next treatment authorization,” with comprehensive assessments generally not to exceed 8 hours every 6 months unless additional justification is provided. Evaluations must be “completed prior to requesting prior authorizations for behavioral assessment or treatment services.”[1]
The DCH credential list, restated: documentation must be established by “a licensed physician or psychologist” or “other licensed professional as designated by Medical Composite Board.” CareSource adds a report-level identity requirement — the initial evaluation results must carry the “evaluator’s name, signature, and credentials” — and a shape requirement: evaluations “should be comprehensive with multiple informants, covering multiple domains.” Primary hearing deficits, speech disorder and heavy metal poisoning “must be ruled out as causal reasons for behavior.”[1][2]
Two tools, one from each side: “completion of 1 acceptable evidence-based tool and 1 caregiver tool (a list can be located in the Georgia Autism Spectrum Disorder Services Policies and Procedures Manual).” The evaluation report must be submitted in report format “with a summary of each individual evaluation instrument, developmental history, and present concerns,” and must include the date completed, a “minimum of 2 assessment tools, including 1 clinician tool and 1 caregiver tool with a summary of each individual assessment,” any tests administered with scores, and the evaluator’s name, signature and credentials. A diagnostic re-evaluation needs at minimum one clinician observational assessment; school psychoeducational assessments are not acceptable.[1]
The state structure, administered in-house. “PA must be requested by the enrolled QHCP,” and the behavioral assessment “is conducted by an independent practitioner who also develops” the plan — with prior authorization required separately for the behavioral assessment and for treatment. The clinical recommendation requirement underneath is the Georgia Medicaid one: 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), and the ordering/prescribing/referring practitioner’s NPI must be on the claim and enrolled in Georgia Medicaid. CareSource reviews against the DCH ASD manual plus MCG criteria and requires signed treatment documentation before claims submission.[1][3][2]
Allowed, with the state’s billing rules and a provider-judgement duty on top. “The provision of ABA services is allowed via telehealth per GA DCH. Part II Policies and Procedures for Autism Spectrum Disorder Services publishes applicable codes, modifiers and allowable provider types. Additionally, Part II Policies and Procedures for Telehealth Guidance provides information for telehealth billing requirements, which is only billable if the provider is in GA or within 50 miles of the GA border when services are rendered.” CareSource then puts the modality decision on the clinician: decisions must be “consistent with best, currently available evidence and clinical consensus,” weighing assessed needs, strengths, preferences and available resources, with the same professional ethics as in-person care and explicit attention to interstate licensure, state regulatory issues, caregiver discomfort with technology, technology limits and cultural acceptance; providers must have protocols for clinical appropriateness and confirm their own competence in the modality.[1][3]
Ask the plan: The 50-mile rule specifically: CareSource attributes it to the DCH Telehealth Guidance, but the version dated 10/1/2025 does not contain it. Confirm with CareSource GA provider services, or against the current guidance inside GAMMIS, before relying on a border-adjacent rendering location.
CareSource's 2026 Georgia manual: "For standard prior authorization decisions, CareSource provides notice to the provider and member as expeditiously as the member's health condition requires, but no later than three business days after receipt of the request for service." "Urgent prior authorization decisions are made within 24 hours of receipt of the request for service." Either can be extended (14 calendar days for standard, 5 business days for expedited) if the member or provider asks, or CareSource justifies it to DCH. That is faster than the federal 7-calendar-day cap and Georgia's 7-day statute. Autism spectrum disorder PAs go through the GAMMIS centralized portal, not the CareSource portal. Timing for renewals: treatment is authorized "in 6-month increments." The reassessment can be done once per 6-month period, "no more than 2 months prior to the effective date of the next treatment authorization." Its results must be dated "no more than 2 months prior to the treatment services PA effective date." Schedule the reassessment inside that two-month window before the current authorization ends.[4][1][5][6]
CareSource follows "the federal regulations that Medicaid programs serve as the payer of last resort," and its ABA policy repeats: "When a member has other insurance, Medicaid is always the payer of last resort. CareSource will not pay more than the Medicaid rate totals for service. The primary payer must provide evidence of determinations for consideration of Medicaid coverage for services." Bill the commercial plan first. When CareSource is secondary, "the provider may submit for secondary payment within 90 calendar days of the primary carrier's EOP, but not more than 12 months from the date of service." A claim denied for missing COB information needs the primary EOB within the remaining timely-filing window. 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][1][7][8][9]
Coverage decides whether CareSource (Georgia Medicaid CMO) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
CareSource restates the DCH structure and adds a reimbursement consequence. The QHCP must supervise non-enrolled practitioners under the enrolled provider identification number of the QHCP and/or facility, performed in accordance with BACB supervision guidelines — and “supervision is not separately reimbursable as it is buil[t] into the direct service code rates.” Who may supervise whom: a licensed physician, licensed psychologist, BCBA-D or BCBA may supervise BCaBAs and RBTs; a BCaBA must be supervised by a physician, psychologist or BCBA/BCBA-D but may supervise RBTs. Supervision records must capture the duration and type of each session plus a brief summary of pertinent activity, kept by both supervisor and supervisee for audit; discrepancies make the associated claims subject to recoupment. Family training must be delivered by the BCBA or BCaBA — an RBT may assist during a family-training session but may not conduct the training or supervise interventions.[1][2]
CareSource publishes the limit, not the permission. “Time reported and billed MUST be face-to-face time with the patient,” and “QHCP billing of protocol modification is not appropriate in instances when documentation supports only supervision or services being performed at a time when the member is not present.” So 97155 billed for supervision with the member absent is a recoupment target. The policy does not state affirmatively whether 97153 and 97155 may be billed for the same clock time when analyst, technician and member are all face-to-face.[1]
Ask the plan: CareSource Provider Services for the same-clock-time question — the policy answers only the negative case.
CareSource adds a parent signature and makes it a claims precondition — this is the rule most likely to cost a Georgia clinic money. The member’s treatment record (plans of care, treatment plans, behavior support plans, functional assessments, daily services notes and progress notes) “must be completed by the provider or practitioner, signed by the parent or legal guardian (if minor age) or by the member if applicable and submitted to CareSource prior to claims submission. Claims will not be accepted without accompanying signed treatment documentation.” On top of that, progress notes must be legible, detailed, complete, signed and dated; signatures must be original and belong to the person who created them and be dated the actual date signed; rubber stamps are not acceptable and electronic signatures only in certain circumstances; records must be real-time, never back-dated, with corrections by single strike-through plus initials and date.[1]
MM-0212 describes ABA as delivered “in centers or at home” and permits telehealth delivery per GA DCH Part II policy, with the provider responsible for judging clinical appropriateness, risk and provider competence for the modality. It sets no separate school or group-home rule of its own.[1]
Ask the plan: For school-based delivery under a CareSource member: CareSource GA provider services, since the policy is silent where Peach State’s is explicit.
Under the QHCP and/or the facility. CareSource repeats the state rule that the QHCP must supervise non-enrolled practitioners “under the enrolled provider identification number of the QHCP and/or facility” — so RBT- and BCaBA-delivered time is claimed on the supervising enrolled provider’s number, not the technician’s.[1][2]
No per-day unit ceiling is published. MM-0212 leaves intensity to medical necessity, noting only that “medical[ly] necessary will determine approved hours per week (eg, typically 10-30 hours)” commensurate with the deficits identified in the behavior assessment.[1]
Blocked on: CareSource GA provider services / the Georgia fee schedule inside GAMMIS.
Yes — CareSource administers the Georgia Medicaid ABA benefit under policy MCD-MM-0212, aligned to the DCH ASD manual, with in-house prior authorization and medical review. Members must be under 21 with an ASD diagnosis.
Effective May 11, 2026, CareSource pays 80% of the Georgia Medicaid fee schedule for covered services. Coverage is unchanged; the reimbursement rate is lower.
The clinical rules align to the DCH ASD manual, but CareSource runs its own PA/medical-review process (using MCG criteria) and requires signed treatment documentation before claims. Always confirm the member's plan at intake.
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.
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