Q2 2024 GA Medicaid Manual Update
New quarter, new manual! Georgia Department of Community Health just released its Quarter 2 Autism Providers Manual. There were some significant changes that will impact systems and processes in organizations across the state.
Unbundling the Family of Codes (FOC). (Previously 97153/97155 and 97157/97158) [Appendix F]
This is going to be one of the most impactful updates of this quarter’s manual. Previously, direct therapy and oversight hours were requested as a family of codes. This allowed for flexibility of oversight and direct services, as the needs of the client changed across an authorization period. This current update requires each code be requested and billed separately.
Provided clarification on the use of 97155 and 97158 [Appendix F]
More significant than the unbundling of FOC, the manual also includes added notes of the use of 97155 and 97158. 97155 is strictly protocol modification and not supervision of RBTs. The manual states: “Supervision rates are built into direct service rates and cannot be billed separately.” This is worrisome as a clinician and supervisor. Agencies are already paying out of pocket to onboard and train new staff. Now one of the largest payors of autism services in the state, has determined that direct instruction on a client’s case is not reimbursable. This is a slippery slope to Medicaid only approving 5% of direct services for program modification and case oversight (rather than industry standard 10%). This is already the case with CareSource, and now Medicaid is following suit. We must act together, to stop allowing insurance companies to mandate what is clinically necessary. I urge all agencies and clinicians in the state, if you are not doing so already, start measuring treatment outcomes of clients who receive 5% versus 10% supervision. I encourage agencies and clinicians to keep reliable records of RBT competencies when they are provided sufficient, client-specific training, and the effect that adequate training has on client outcomes.
Added guidelines related to using assessments and POCs from other providers [Section 801.1]
I hypothesize, this modification was added for a reason. What’s the first thing we do when we get a new client…ASSESS! Don’t take someone else’s word for it. Folks, complete your own assessment and treatment plan, when receiving a client from another provider.
Reassessments may be 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) [Section 801]
Providers must allow up to 45 calendar days for auth request to be reviewed and a decision to be made [Appendix G]
I grouped these two, because the first item isn’t that far off from what the manual initially read. However, adding that providers must allow up to 45 calendar days for auth requests to be reviewed is pushing the timeline a bit. So, the assessment must be completed no more than 2 months prior to the effective date, but we also need to have the auth request submitted at least 45 calendar days prior to the effective date. That’s a narrow window to complete the assessment, write the progress report, and submit for approval. To keep up with these demanding timelines, clinicians and agencies must beef up their progress monitoring and assessment processes, to ensure adequate time for completion and submission.
Providers must allow up to 10 days for an appeal/reconsideration to be reviewed and a decision to be made [Appendix G]
Same as above goes for appeals and reconsiderations. They have up to 10 days to make a decision! To ensure there’s no lapse in services, make sure submissions are timely.
Added guidance for school plans [Section 801.2.2]
“School plans will be reviewed for medical necessity; clinical documentation must be clearly outlined to detail the maladaptive behaviors that client exhibits that requires the need for intensive support services in the school setting (pg 14).”
It’s been hopeful that more and more language has been added to the manual over the past few updates regarding school plans and services. Now we just need to get the schools on board. I’ve had limited success having schools allow outside staff in for support. If anyone has had more broad success, I’d love to hear what’s working!
New cover page [Appendix F]
There’s a new cover page. The most significant changes include an updated Acceptable Tools List, and an update CPT Code table.
What are your thoughts on the manual updates? How are you and your agency adapting to the new requirements? I’d love to hear your thoughts.
