Beginning July 1, 2017, the Georgia Families® program will provide Members a choice of four Care Management Organizations (CMOs): Amerigroup, CareSource, Peach State Health Plan, and WellCare. Georgia Families® Members were given the opportunity to select a CMO during the Open Enrollment process which took place during the month of March 2017. Some Members who did not make affirmative selections were auto-assigned to a CMO. During the choice change period of July 1, 2017 through September 30, 2017, all Members will have a one-time opportunity to change their assigned CMO without cause. The change will become effective on the first day of the month after the change is requested. In order to ensure a smooth transition and that all Members have access to care, each CMO has implemented Transition of Care processes which include the following:
Existing/Open Prior Authorizations:
If you are rendering services to a Member who has a newly assigned CMO effective July 1, 2017, the newly assigned CMO will honor any current/open Prior Authorizations for forty-five (45) days beginning on July 1, 2017 through August 14, 2017. This applies to in-network and out-of-network (non-par) Providers. Thus, if you are rendering services to a Member who has a newly-assigned CMO, and you are not contracted with the newly-assigned CMO, the newly-assigned CMO will honor any current/open Prior Authorizations for forty-five (45) days beginning on July I, 2017 through August 14, 2017. If the Member requires services beyond August 14, 2017, Providers must contact the Member’s new CMO to obtain authorization to continue services. Providers will be required to follow the new CMO’s prior authorization process for any continued services the Member needs.
New Requests for Prior Authorization (i.e., requests submitted on or after July 1, 2017):
Providers will be required to submit new requests for Prior Authorization based upon the applicable CMO’s guidelines. This applies to in-network and out-of-network (non-par) Providers. Prior authorization decisions for non-urgent services will be made within three (3) business days. Expedited service authorization decisions will be made within twenty-four (24) hours.
Pharmacy-Related Prior Authorizations:
Each CMO will honor prescriptions ordered/issued prior to July 1, 2017. All current prescriptions (including medication step therapy) will be transitioned and honored by the new CMO for a period of forty-five (45) days, beginning on July 1, 2017 and ending on August 14, 2017. This is part of the Transition of Care process. Claims Reimbursement for Office Visits and Sick Visits for Out-of-Network Providers (Non-Par)
If you are rendering services to a Member who has a newly-assigned CMO effective July 1, 2017, and you are an out-of-network Provider, you may submit claims for reimbursement for office-based and sick visits rendered to Georgia Families® Members and Planning for Healthy Babies® enrollees without an authorization. Claims may be submitted to Amerigroup, CareSource, Peach State Health Plan, and WellCare by out-of-network Providers for services provided from July 1, 2017 through August 14, 2017. In all instances timely filing requirements must be met.
Please Note: Effective Friday, June 23, 2017, Providers will be able to submit CareSource PAs via the Centralized PA Portal. All PAs associated with the Centralized PA Portal will be processed for CareSource members beginning on July 1, 2017.
The following forms are currently associated with the Centralized PA Portal:
• Newborn Delivery Notification
• Pregnancy Notification
• Inpatient Hospital Admissions and Outpatient Procedures
• Hospital Outpatient Therapy
• Durable Medical Equipment
• Children ‘s Intervention Services
• Outpatient Behavioral Health
For any other CareSource PA submissions, please refer to https:/iwww.caresource.com/providers/georgia/, call 1-855-202-1058, or email email@example.com.
Department of Community Health