Peach State Health Plan ABA coverage (GA Medicaid CMO).

0373T requirements

Requests need an extra-technician plan, environmental modifications per target behavior, a titration plan toward 97153, and a BCBA on-site and immediately available.^[1]

Under 21 — GA.CP.BH.504 makes it the first medical-necessity criterion: “member/enrollee is under the age of 21 years.” Two participation conditions sit alongside it: the member must exhibit behaviors presenting “clinically significant health or safety risk to self or others” or “significantly interfering with basic self-care, communication, or social skills,” and “member/enrollee and caregivers can participate in adaptive behavioral services (ABS) and can implement ABS techniques in the home environment as instructed by the behavior analyst.”^[1]

Five years, stated outright — and the only Georgia plan that writes the renewal trigger as cleanly. At treatment initiation, “the CDE has been completed within the last five years.” For treatment continuation, a “diagnostic re-evaluation to re-confirm diagnosis” is required when any of the following apply: “provisional diagnosis of ASD”; “no formal psychological or neuropsychological evaluation was completed”; or “more than five years have passed since the initial diagnosis and there is no evidence of ongoing assessment and treatment.” Separately, the behavioral assessment or reassessment “must be completed at least every six months or no more than 2 months prior to the start of the initial treatment” authorization, and reauthorization needs “results of a recent behavior assessment (within two months).”^[1]

A licensed clinician, with the evaluation signed and attributable: the member must have “a documented diagnosis of autism spectrum disorder (ASD) established by a licensed physician, psychologist, or other qualified licensed professional,” and the CDE report must document the “evaluator’s name, legible signature, and credentials” alongside each test administered “with scores and date originally completed.” The hard exclusion intake should screen for first: “school psychoeducational assessments are not acceptable for a diagnostic evaluation.” The CDE must also document direct observation and a parent/caregiver interview, and physical health concerns — medical concerns, speech deficits, hearing deficits, heavy metal poisoning — must have been “evaluated and ruled out as causal reasons for behavior.”^[1]

A minimum of two, one from each named list — the most explicit instrument requirement published by any Georgia payer. “A minimum of two assessment tools (one primary clinician tool and one caregiver tool).” Primary clinician tool, one of: ADOS-2; GARS-3; CARS2 ST/HF; STAT; Communication and Symbolic Behavior Scales (CSBS); TELE-ASD-PEDS; Naturalistic Observational Diagnostic Assessment (NODA); DISCO; RITA-T; Autism Detection in Early Childhood (ADEC); EarliPoint; Canvas DX. Caregiver tool, one of: ADI-R; DISCO; CARS Parent Questionnaire (CARS QPC); GARS-3; Social Communication Questionnaire (SCQ); M-CHAT; SRS-2; Autism Spectrum Rating Scale (ASRS); Autism Behavior Checklist (ABC); Toddler Autism Symptom Inventory (TASI); BASC; PDD-BI; PEDS:DM; ASQ-3; ASQ:SE2; Conners Behavior Rating Scale (CBRS); Child Development Inventory (CDI); CSBS DP Infant-Toddler Checklist. Each requires a summary of the individual assessment, the score and the original completion date.^[1]

A physician recommendation, and it is a listed medical-necessity criterion rather than paperwork: “requested services have been recommended by a licensed physician or other qualified licensed practitioner of the healing arts acting within their scope of practice under state law” — the 42 CFR 440.130(c) formula. Assessment and treatment are authorized separately: “requests for behavioral assessments and treatment services are completed separately and authorized independently.” The treatment PA package adds the Letter of Medical Necessity and the Medicaid Cover Page, and the Georgia rule that the PA be requested by the enrolled QHCP and that the ordering/referring practitioner’s NPI appear on the claim applies underneath.^[1][2]

GA.CP.BH.504 acknowledges telehealth as a modality — services “may be provided in various settings (e.g., home, clinic, school, community) and modalities (e.g., in-person, telehealth)” — but publishes no rule of its own: no code list, no modifier, no place-of-service guidance and no limit. The operative floor is the DCH Part II Telehealth Guidance (version date 10/1/2025), which does carry an ASD section: ABS codes 97151–97158, 0362T and 0373T are billable by telehealth in 15-minute units with the GT modifier and the U1–U5 practitioner-level modifier, on POS 02 (member outside the home) or POS 10 (member at home), with prior authorization unchanged.^[3][1]

Ask the plan: Peach State / Centene provider services for any plan-level telehealth restriction on ABS, since GA.CP.BH.504 is silent where its other criteria are explicit.

Peach State's April 2026 manual: "Prior Authorization decisions for nonurgent services shall be made within three (3) Business Days, or other established timeframe, of the request (generally submitted one week prior to the service or procedure)." It may add 14 calendar days if the member or provider asks, or Peach State justifies needing more information to DCH. The same paragraph later refers to "the original fourteen (14) day determination timeframe," so hold Peach State to three business days and escalate past that. Expedited decisions come "within twenty-four (24) clock hours," with notice "no later than 72 clock hours after receipt of the request for service." Renewals: the reassessment must be "completed at least every six months or no more than 2 months prior to the start of the initial treatment authorization." Its data and graphs must be dated "no more than two (2) months prior to the Treatment Services PA request effective date." Plan the reassessment inside the two months before the authorization ends, and submit about a week ahead.^[4][1][5][6]

Peach State: "Medicaid is the payor of last resort, therefore Peach State Health Plan will make every effort to cost avoid claims or services that are subject to payment from a third party health insurance carrier." Providers "must bill the primary payor prior to billing Peach State Health Plan." Peach State then pays up to its allowable, including the member's commercial copay, coinsurance and deductible, but never more than it would have paid as primary. Secondary claims "must be received within 180 days of the date of the primary carrier's EOP, but never more than twelve (12) months from the month of service." Exception: "Cost avoidance applies to all covered services except claims for EPSDT." Peach State "utilizes the 'Pay and Chase' approach as required" and "complies with Georgia Medicaid COB policies." The manual does not say whether ABA claims count as EPSDT claims. 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]

Ask the plan: Peach State Provider Services (1-866-874-0633) — ask whether ABA claims for members under 21 count as "claims for EPSDT" under the cost-avoidance exception.

Peach State is the Georgia plan that publishes a hard supervision floor: “Adaptive Behavior Treatment with Protocol Modification occurs for at least two hours per week or 10% of the direct service hours provided, whichever is greater.” For a 30-hour week that is three hours of 97155, not two. Separately, any request using 0373T “must include a BCBA who is onsite and immediately available to join the session.”^[1]

Peach State works in hours per day and per week rather than a per-code MUE table. Treatment hours must “not exceed six hours per day up to a total of 30 hours per week,” unless clinical documentation justifies more (high-intensity, high-frequency behaviors or significant skill deficits). The treatment plan must also reflect the child’s school attendance — the policy names “less than 20 hours per week if attending school full-time” as the benchmark — and must build in rest, nutrition breaks and peer-interaction time.^[1]

School delivery is allowed but gated by a separate school plan — the most operationally demanding place-of-service rule in Georgia. “A school plan is required for all educational settings to include home school, public and private schools (with exception only for daycare or after-school settings).” In school, the plan of care must define the behaviors targeted for reduction specific to that setting, list behavior-reduction goals and include line graphs meeting the ASD policy graph rules; skill-acquisition goals “should not be implemented in this setting.” Training school personnel is not reimbursable. Reauthorization data must be collected across all treatment settings — home, school, clinic, community. And ABA delivered “in lieu of school, respite care, or other community-based settings of care” is a discharge criterion, not a covered service.^[1]

Peach State’s ASD policy sets no separate rule, so the Georgia DCH floor governs: BCaBAs and RBTs are not independently enrolled, and their time is claimed under the supervising QHCP’s and/or the facility’s enrolled provider number with the U1–U5 practitioner-level modifier and the U6/U7/GT setting modifier.^[1][2]

Ask the plan: Confirm the modifier set against the current Georgia fee schedule in GAMMIS before a first submission.

Not stated. GA.CP.BH.504 reproduces the AMA descriptor for 97155 — “which may include simultaneous direction of technician, face-to-face with one patient” — but sets no same-clock-time billing rule of its own for 97153 alongside 97155.^[1]

Ask the plan: Peach State / Centene provider services, and the Georgia fee schedule inside GAMMIS.

Not addressed for session notes. The policy does require the diagnostic evaluation to carry the “evaluator’s name, legible signature, and credentials,” but says nothing about who signs each treatment session note or when.^[1]

Blocked on: Peach State provider manual / provider services; Georgia DCH’s documentation standard (writer signs and dates, real time, no back-dating) is the applicable floor.