---
title: Peach State Health Plan ABA coverage (GA Medicaid CMO).
url: "https://carelu.com/payers/peach-state-georgia"
markdown_url: "https://carelu.com/payers/peach-state-georgia.md"
state: GA (Georgia)
payer: Peach State Health Plan (GA Medicaid CMO)
kind: Medicaid managed care plan (MCO)
parent_program: Georgia Medicaid
description: "How Peach State Health Plan administers ABA for Georgia Medicaid — policy GA.CP.BH.504 aligned to the DCH ASD manual, hour parameters, the 80%-attendance rule, and 0373T requirements."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

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

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

> GA.CP.BH.504; hour parameters + 80%-attendance rule; 0373T rules.

Peach State Health Plan is a Georgia Medicaid CMO that administers the ABA benefit under clinical policy GA.CP.BH.504, with prior-authorization criteria explicitly based on the DCH Part II ASD manual. For families carrying Peach State, this is the plan-level layer on top of the state rules.

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 — criteria based on the DCH ASD manual [1]
- **Prior auth for treatment**: Required — criteria based on the DCH ASD manual [1]
- **Autism diagnosis required?**: Yes — DSM-5 ASD per the DCH ASD manual [1][2]

## At a glance

- **Plan type:** Georgia Medicaid CMO (managed care)
- **Policy:** GA.CP.BH.504 (ASD services), based on the DCH manual
- **Hours:** ≤6 hrs/day up to 30/week unless clinically justified
- **Students:** <20 hrs/week if attending school full-time
- **Attendance:** Below 80% of authorized hours requires justification
- **Note:** Lost the 2024 CMO rebid (protest pending) — watch status
- **Diagnosis recency:** Eval within 5 years (DCH-aligned criteria)

## Utilization parameters

Peach State's PA criteria follow the DCH ASD manual. Hour parameters: no more than 6 hours per day, up to 30 hours per week unless clinically justified; fewer than 20 hours per week for full-time students; protocol modification (97155) at least 2 hours per week or 10% of direct hours. If attendance falls below 80% of authorized hours, justification documentation is required — which makes capturing realistic family availability at intake a reauthorization safeguard. [1]

- **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]

## Intake gates

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

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

## Delivery and billing rules

Coverage decides whether Peach State Health Plan (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**: 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]
- **Daily limits / MUEs**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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.
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.

## What intake should collect for Peach State Health Plan (GA Medicaid CMO)

- **Peach State member ID:** Confirm the plan — it determines the PA process and forms.
- **DSM-5 ASD diagnosis:** Per the DCH manual criteria Peach State follows.
- **Realistic availability:** The 80%-attendance rule makes accurate availability a first-order intake question.
- **School status:** Full-time school attendance caps weekly hours below 20 — capture it up front.

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

## Verification of benefits (VOB) data

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

### EDI routing

- **Payer ID (pVerify):** 00385
- **Payer ID (Availity):** 68069
- **Payer ID (Change Healthcare / Optum):** 68069
- **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 | Not published in GA.CP.BH.504; the statewide GA DCH/CMS-mandated daily caps (see the Georgia Medicaid and CareSource entries) are assumed to apply absent a Peach State-specific table. per day (inferred) | home, clinic, school, community, telehealth (modality named; no POS numbers given) | Allowed as a modality per GA.CP.BH.504's general language; code-specific modifier/POS numbers are not published — inferred to follow GA DCH mechanics (GT modifier, POS 02/10). | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth — not restated in GA.CP.BH.504 |
| 97152 | Yes | Required | Not published in GA.CP.BH.504; the statewide GA DCH/CMS-mandated daily caps (see the Georgia Medicaid and CareSource entries) are assumed to apply absent a Peach State-specific table. per day (inferred) | home, clinic, school, community, telehealth (modality named; no POS numbers given) | Allowed as a modality per GA.CP.BH.504's general language; code-specific modifier/POS numbers are not published — inferred to follow GA DCH mechanics (GT modifier, POS 02/10). | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth — not restated in GA.CP.BH.504 |
| 97153 | Yes | Required | Not published in GA.CP.BH.504; the statewide GA DCH/CMS-mandated daily caps (see the Georgia Medicaid and CareSource entries) are assumed to apply absent a Peach State-specific table. per day (inferred) | home, clinic, school, community, telehealth (modality named; no POS numbers given) | Allowed as a modality per GA.CP.BH.504's general language; code-specific modifier/POS numbers are not published — inferred to follow GA DCH mechanics (GT modifier, POS 02/10). | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth — not restated in GA.CP.BH.504 |
| 97154 | Yes | Required | Not published in GA.CP.BH.504; the statewide GA DCH/CMS-mandated daily caps (see the Georgia Medicaid and CareSource entries) are assumed to apply absent a Peach State-specific table. per day (inferred) | home, clinic, school, community, telehealth (modality named; no POS numbers given) | Allowed as a modality per GA.CP.BH.504's general language; code-specific modifier/POS numbers are not published — inferred to follow GA DCH mechanics (GT modifier, POS 02/10). | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth — not restated in GA.CP.BH.504 |
| 97155 | Yes | Required | Not published in GA.CP.BH.504; the statewide GA DCH/CMS-mandated daily caps (see the Georgia Medicaid and CareSource entries) are assumed to apply absent a Peach State-specific table. per day (inferred) | home, clinic, school, community, telehealth (modality named; no POS numbers given) | Allowed as a modality per GA.CP.BH.504's general language; code-specific modifier/POS numbers are not published — inferred to follow GA DCH mechanics (GT modifier, POS 02/10). | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth — not restated in GA.CP.BH.504 |
| 97156 | Yes | Required | Not published in GA.CP.BH.504; the statewide GA DCH/CMS-mandated daily caps (see the Georgia Medicaid and CareSource entries) are assumed to apply absent a Peach State-specific table. per day (inferred) | home, clinic, school, community, telehealth (modality named; no POS numbers given) | Allowed as a modality per GA.CP.BH.504's general language; code-specific modifier/POS numbers are not published — inferred to follow GA DCH mechanics (GT modifier, POS 02/10). | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth — not restated in GA.CP.BH.504 |
| 97157 | Yes | Required | Not published in GA.CP.BH.504; the statewide GA DCH/CMS-mandated daily caps (see the Georgia Medicaid and CareSource entries) are assumed to apply absent a Peach State-specific table. per day (inferred) | home, clinic, school, community, telehealth (modality named; no POS numbers given) | Allowed as a modality per GA.CP.BH.504's general language; code-specific modifier/POS numbers are not published — inferred to follow GA DCH mechanics (GT modifier, POS 02/10). | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth — not restated in GA.CP.BH.504 |
| 97158 | Yes | Required | Not published in GA.CP.BH.504; the statewide GA DCH/CMS-mandated daily caps (see the Georgia Medicaid and CareSource entries) are assumed to apply absent a Peach State-specific table. per day (inferred) | home, clinic, school, community, telehealth (modality named; no POS numbers given) | Allowed as a modality per GA.CP.BH.504's general language; code-specific modifier/POS numbers are not published — inferred to follow GA DCH mechanics (GT modifier, POS 02/10). | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth — not restated in GA.CP.BH.504 |
| 0362T | Yes | Required | Not published in GA.CP.BH.504; the statewide GA DCH/CMS-mandated daily caps (see the Georgia Medicaid and CareSource entries) are assumed to apply absent a Peach State-specific table. per day (inferred) | home, clinic, school, community, telehealth (modality named; no POS numbers given) | Allowed as a modality per GA.CP.BH.504's general language; code-specific modifier/POS numbers are not published — inferred to follow GA DCH mechanics (GT modifier, POS 02/10). | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth — not restated in GA.CP.BH.504 |
| 0373T | Yes | Required | Not published in GA.CP.BH.504; the statewide GA DCH/CMS-mandated daily caps (see the Georgia Medicaid and CareSource entries) are assumed to apply absent a Peach State-specific table. per day (inferred) | home, clinic, school, community, telehealth (modality named; no POS numbers given) | Allowed as a modality per GA.CP.BH.504's general language; code-specific modifier/POS numbers are not published — inferred to follow GA DCH mechanics (GT modifier, POS 02/10). | Inferred: GA DCH U1–U7 tiers/setting modifiers, GT telehealth — not restated in GA.CP.BH.504 |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T:** Verify via: Peach State UM/PA portal — GA.CP.BH.504 publishes no unit-cap table or modifier list of its own.
- **0373T:** Requires an extra-technician plan, environmental modifications per target behavior, a titration plan toward 97153, and a BCBA onsite and immediately available (per GA.CP.BH.504). Verify via: Peach State UM/PA portal — GA.CP.BH.504 publishes no unit-cap table or modifier list of its own.

### Contacts

- **Provider services phone:** 1-866-874-0633
- **Hours:** Monday–Friday, 7:00 a.m.–7:00 p.m.
- **Portal:** [Peach State Provider Secure Portal](https://provider.pshpgeorgia.com)
- **Fax:** 1-877-683-3155

Questions to ask on a verification call:

- Is the ABA cost share a copay or coinsurance, and is it charged per visit or per day?
- Which service-type-code bucket does Peach State return ABA benefit detail under?
- Does the deductible apply to ABA codes?
- Does the out-of-pocket maximum apply to ABA cost share?
- Does Peach State follow the statewide GA DCH/CMS daily unit caps for ABA codes, or does it publish its own unit-cap table?
- Does eligibility checking return real-time or batch-only 271 responses?

### 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://www.pshpgeorgia.com/content/dam/centene/peachstate/policies/clinical-policies/GA.CP.BH.504.pdf (accessed 2026-07-23)
- https://www.pshpgeorgia.com/content/dam/centene/peachstate/pdfs/508_PSHP-GA-Provider-QRG.pdf (accessed 2026-07-23; source document older than 18 months)

## Common questions

### Does Peach State Health Plan cover ABA therapy?

Yes — Peach State administers the Georgia Medicaid ABA benefit under policy GA.CP.BH.504, with prior-authorization criteria based on the DCH ASD manual, for members under 21 with ASD.

### What are Peach State's ABA hour limits?

Generally no more than 6 hours/day up to 30 hours/week unless clinically justified, and under 20 hours/week for full-time students. Attendance below 80% of authorized hours requires justification.

### Is Peach State staying a Georgia Medicaid CMO?

Peach State lost the December 2024 CMO rebid and filed a protest; the transition timeline has been in flux. Confirm the member's current plan and any transition at intake.

## Primary sources

1. [Peach State — GA.CP.BH.504 (ASD services)](https://www.pshpgeorgia.com/content/dam/centene/peachstate/policies/clinical-policies/GA.CP.BH.504.pdf)
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. [Peach State Health Plan Provider Manual (April 2026)](https://www.pshpgeorgia.com/content/dam/centene/peachstate/pdfs/GA-INT-11666%20Provider%20Handbook%20Update%202026%20FINAL%202_R.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.