Georgia Medicaid ABA coverage: the intake guide.

The treatment PA package

Diagnosis + summarized assessment results, proposed Plan of Care (documenting all other services), IFSP/IEP if applicable, psych assessment if applicable, progress notes, and — for CMOs — a Letter of Medical Necessity and the Medicaid cover page.^[2]

Assessment recency

Outside assessments are accepted if dated within 6 months of the request; comprehensive assessments are generally capped at 8 hours per 6-month period.^[2]

Reauthorization every 6 months

Requires a behavior assessment conducted within 2 months of the requested effective date, progress vs. prior goals (with graphs), and updated individualized goals.^[2]

Under 21. The posted ASD manual states it plainly under General Eligibility: “Autism Spectrum Services are for individuals under the age of 21.” The current DCH Telehealth Guidance (version date 10/1/2025) confirms the same footing from a document that is not stale — ASD assessment and treatment are “provided to Medicaid beneficiaries in accordance with the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Benefit and according to medical necessity.” Two further eligibility conditions sit alongside the age bound: “children must be able to participate in sessions,” and caregivers “must be able to participate in ABS therapy and have the ability to implement ABS techniques in the home environment.”^[2][10]

The posted manual sets one recency rule, and it is about the assessment rather than the diagnosis: “Medicaid will accept for submission the findings from an assessment that was not approved/covered by Medicaid… as long as the assessment was conducted/dated no more than six (6) months prior to the treatment PA request submission.” On the diagnosis itself the manual says only that it “should be made and confirmed in early childhood.” The five-year evaluation window Georgia families actually meet is a CMO operationalisation, not a posted state rule — CareSource requires a diagnostic re-evaluation when “the initial diagnosis is at least 5 years old with no evidence of ongoing assessment and treatment,” and Peach State requires the CDE to have been “completed within the last five years” at treatment initiation. Sourcing caveat: the ASD manual publicly posted on medicaid.georgia.gov is the January 2018 version and is known to be stale — its Appendix A still prices the retired 0359T–0374T code set — while the current quarterly manuals and live fee schedule sit inside GAMMIS (mmis.georgia.gov), which refuses automated clients outright.^[2][4][5]

Ask the plan: The current ASD manual inside GAMMIS (mmis.georgia.gov) for whether DCH has since adopted the five-year window itself; in the meantime route by the member’s CMO policy.

Two requirements stack. Credential: “a documented diagnosis of ASD must be established by a licensed physician or psychologist, or other licensed professional as designated by the Medical Composite Board in order to perform a behavioral assessment and develop a resulting Plan of Care.” Experience: “the diagnosis must be made by a practitioner with one year of experience in serving individuals with an autism diagnosis who is also enabled by the OCGA practice acts to diagnose behavioral health/intellectual/developmental conditions” — a one-year ASD-experience test on the diagnostician that intake should actually check, not assume. The enrolled QHCP then re-validates at assessment: “based on the assessment, the QHCP validates the individual’s diagnosis of ASD and identifies the severity level… according to the DSM-5 manual,” and if the diagnosis is not validated the QHCP refers the member elsewhere. Sourcing caveat: the ASD manual publicly posted on medicaid.georgia.gov is the January 2018 version and is known to be stale — its Appendix A still prices the retired 0359T–0374T code set — while the current quarterly manuals and live fee schedule sit inside GAMMIS (mmis.georgia.gov), which refuses automated clients outright.^[2]

The posted manual asks for one tool, not two: “diagnosis should be made and confirmed in early childhood using one of the following tools: Autism Diagnostic Observation Schedule (ADOS), Autism Diagnostic Interview (ADI), the Diagnostic Interview for Social, Communication Disorders (DISCO), and/or other known evidence based tools.” For the behavioral assessment it adds that “the QHCP must use valid and reliable evaluation tools that conform to industry standards (such as the ADOS).” Three conditions must be ruled out as causal: primary hearing deficits, primary speech disorder, and heavy metal poisoning. Treat the one-tool floor as a floor only — the two-instrument requirement families actually face (one clinician-administered tool plus one caregiver tool) comes from the CMOs, and school psychoeducational assessments are not acceptable as a diagnostic evaluation on any of them. Sourcing caveat: the ASD manual publicly posted on medicaid.georgia.gov is the January 2018 version and is known to be stale — its Appendix A still prices the retired 0359T–0374T code set — while the current quarterly manuals and live fee schedule sit inside GAMMIS (mmis.georgia.gov), which refuses automated clients outright.^[2][5][4]

Ask the plan: The current ASD manual inside GAMMIS for the live instrument list; Peach State GA.CP.BH.504 and CareSource MCD-MM-0212 publish the operative two-tool requirement openly.

Two separate gates, and only one of them is what intake usually means by “referral.” Clinically, 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 “all ABS PAs must be requested by the enrolled QHCP” — a licensed physician, psychologist, BCBA-D or BCBA; BCaBAs and RBTs cannot serve as the QHCP. Administratively, the ordering, prescribing or referring practitioner’s NPI must appear on the claim — on the CMS-1500 “enter qualifiers to indicate if the claim has an ordering, referring, or prescribing provider to the left of the dotted line in box 17 (Ordering = DK; Referring = DN or Supervising = DQ)” — and that practitioner must be enrolled in Georgia Medicaid, or the claim denies. The treatment PA package also carries the IFSP/IEP where applicable.^[10][2]

Georgia publishes a real telehealth benefit for ABS, and the best current source for it is not the ASD manual — it is the DCH Part II Telehealth Guidance (version date 10/1/2025), which carries its own ASD section. “Practitioners of ASD services can use telehealth to assess, diagnose and provide therapies to patients,” provided they hold a current Georgia medical or psychology licence or a valid ABA certification; Georgia Medicaid enrols BCBAs as QHCPs for this purpose. The guidance publishes a current Category I code table for telehealth ABS — 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T, each in 15-minute units with the GT modifier and the U1–U5 practitioner-level modifier (U1 physician/psychiatrist, U2 psychologist or BCBA-D, U3 BCBA, U4 BCaBA or master’s-level behavior analyst, U5 RBT). On the claim, “the GT modifier is required as applicable, and/or the use of either POS 02 or POS 10,” where POS 02 is telehealth outside the patient’s home and POS 10 is telehealth in the patient’s home; CPT modifier 93 may be appended for audio-only services where appropriate. Prior authorization applies to telehealth ABS exactly as it does in person. Worth noting for the code-set question generally: this DCH document carries the Category I 97151–97158 set, while the posted January 2018 ASD manual still prices 0359T–0374T.^[10]

Ask the plan: Whether Georgia still limits telehealth billing to a rendering provider located in Georgia or within 50 miles of the state line — CareSource MCD-MM-0212 states that rule and attributes it to this guidance, but the 10/1/2025 version does not contain it. Confirm in GAMMIS (mmis.georgia.gov) or with DCH before relying on either reading.

Federal law sets the ceiling, and Georgia's CMOs publish a faster clock. For fee-for-service members, the state must decide a standard prior authorization "in no case later than 7 calendar days after receiving the request" (beginning January 1, 2026). It may add up to 14 calendar days if the family or provider asks or the state needs more information. Expedited requests are due "no later than 72 hours." CMO members fall under the federal managed-care cap of 7 calendar days from receipt (42 CFR 438.210(d)), plus Georgia's prior-authorization law. That law applies to DCH's CMO contracts (O.C.G.A. 33-46-30): notice "within 7 calendar days of obtaining all necessary information," 72 hours for urgent, and "automatic authorization" when a deadline is missed. All three CMOs' current manuals print a stricter standard: three business days for a standard request and 24 hours for an expedited one. ABS is authorized "in six (6) month increments," with the assessment and treatment PAs requested separately. The posted ASD manual sets no lead time for reauthorization.^{[12][13][14][15][16][17][2]}

Georgia Medicaid pays last. DCH's Part I manual (version date July 1, 2026): "other available third-party resources must be exhausted before Medicaid/PeachCare for Kids pays." Providers must file "with the appropriate primary health plan(s) prior to filing with Medicaid" and list the other insurers and their payments on the claim. Medicaid pays only the gap up to its own maximum allowable. 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." A claim the primary plan denied because the provider did not follow its rules is not paid: DCH "will not reimburse the provider submitted charges denied by the primary plan because of the provider's failure to follow the primary plan's rules." So get the commercial PA as well. A service the primary plan does not cover, or where its annual or lifetime limits are exhausted, "is reimbursable up to the Medicaid/PeachCare for Kids maximum allowable amount." EPSDT exception: "A provider is not required to exhaust other health plan benefits with respect to claims for preventive and pediatric services including health check (also known as EPSDT)." The manual does not say whether ABS claims fall under it. 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."^{[18][19][20][21][22]}

Ask the plan: The member's CMO or the GAMMIS TPL unit (678-564-1162, option 3) — ask whether an ABS claim for a child under 21 is paid under the EPSDT exception without the primary EOB.

Georgia runs a caseload cap, not a percentage floor. Under the DCH manual a physician, psychiatrist, BCBA-D or BCBA — the enrolled Qualified Health Care Provider (QHCP) — may supervise up to six certified BCaBAs and RBTs at any point in time, and the attestation appendix caps a licensed non-BCBA supervisor (a physician, say) at three practitioners. “Supervision” is defined as direct clinical review for training or teaching and does NOT require the supervisor to be present at the work site. Both supervisor and supervisee must keep a contemporaneous record of the date, duration, type and a brief summary of each supervision session, producible on audit; discrepancies make the associated claims subject to recoupment. A BCaBA must be supervised by a BCBA/BCBA-D but may supervise RBTs; an RBT can never be the QHCP. Every supervised direct-care professional must attest to one year of ASD experience, and the Attestation must be resubmitted within two weeks of any staffing change.^[2]

The person who wrote the note signs it — the manual imposes no supervising-analyst co-signature. Records must contain “progress notes that are legible, detailed, complete, signed and dated,” and every signature must be “legible, original and belong to the person creating the signature”; if illegible the name must also be printed. All signatures must be dated the actual date signed, rubber-stamp signatures are not accepted, and electronic signatures are accepted only in the circumstances set out in Part I § 106. Records must be documented in ‘real time’ and not back-dated; corrections take a single strike-through plus the corrector’s initials and date, never whiteout.^[2]

Georgia prices by setting rather than restricting it: every ABS line carries a service-location modifier — U6 in-clinic, U7 out-of-clinic (paid at a materially higher rate), GT telemedicine — alongside the practitioner-level modifier. The posted manual sets no school, community or group-home rule of its own; the school-setting requirements an intake team will actually meet are in the CMO policies (Peach State requires a separate school plan for every educational setting).^[2]

Ask the plan: For school and group-home delivery specifically: the member’s CMO policy, and the current ASD manual inside GAMMIS.

The claim goes out under the enrolled QHCP and/or the facility. BCaBAs and RBTs “are not enrolled directly by the Division as providers because they are not independent practitioners” — their services are claimed under the enrolled provider identification number of the supervising QHCP and/or the facility, and if the payee is a facility the QHCP must attest under the facility Medicaid ID and list all supervisees. Practitioner level rides as a modifier: U1 physician/psychiatrist, U2 psychologist or BCBA-D, U3 BCBA, U4 BCaBA or master’s-level analyst with a year of ASD experience, U5 RBT with a year of ASD experience — plus the setting modifier (U6/U7/GT). Separately, the ordering/prescribing/referring practitioner’s NPI must appear on the claim (CMS-1500 box 17, qualifier DK ordering, DN referring, DQ supervising) and that practitioner must be Georgia-Medicaid-enrolled or the claim is denied.^[2]

Not answered by the publicly posted manual. The January 2018 Part II ASD manual on medicaid.georgia.gov predates the Category I adaptive-behavior code set — its Appendix A still prices 0359T–0374T — and it contains no concurrent-services or same-clock-time provision for 97153 with 97155. Current quarterly manuals and the live fee schedule sit inside GAMMIS, which blocks automated retrieval.

Blocked on: GAMMIS (mmis.georgia.gov) provider manual + fee schedule for the current ASD policy, or the member’s CMO policy — CareSource MCD-MM-0212 and Peach State GA.CP.BH.504 are the ones published openly.

No per-day unit ceiling is published in the posted manual. DCH sets utilization by prior approval and the Chapter 903 service limitations rather than a per-code MUE table, and the manual’s only quantitative guidance is that therapy “can range from 10-30 hours per week, or more if medically necessary.” Whether Georgia applies the Medicaid NCCI MUE table, the Practitioner MUE table, or its own fee-schedule limits is not stated in the posted document.^[2]

Blocked on: GAMMIS fee schedule and current ASD manual; for a managed-care member, the CMO’s claim-edit policy (Peach State publishes 6 hrs/day · 30 hrs/week; Amerigroup publishes weekly ceilings).