Georgia GA

GA Medicaid FFS prior-approval criteria are NOT a single PA grid and NOT per-MCO for fee-for-service. They live inside ~70 per-provider-type "Current Policy Manuals" published by DCH on the GAMMIS Public Access portal (Gainwell-operated, mmis.georgia.gov). Each manual (Hospital Services, DME, Dialysis, Ambulatory Surgical, Autism, etc.) contains a Prior Authorization/Prior Approval section plus appendices listing codes/procedures requiring prior approval. Manuals are versioned quarterly (current = Q2 / 04-01-2026) and served as direct static PDFs under /portal/Portals/0/StaticContent/Public/ALL/Handbooks/. The portal is public (no login for manuals); interactive PA submission/lookup is behind login. Georgia Families managed care (4 CMOs: Amerigroup/Wellpoint, CareSource, Peach State, WellCare) delegates PA per-CMO on top of this. Pharmacy: FFS via DCH PDL through GAMMIS; per-CMO PBM for managed care. Prior findings #2/#3 framed GAMMIS as a Centralized Prior Authorization Portal using CareSource-page scope text; the accurate FFS shape is the provider-manual library documented here.

carve_in_to_mco_pbms_with_state_mandated_pass_through

Inpatient hospital admissions, outpatient hospital, ASC procedures, outpatient behavioral health (excl. psych testing, IOP, PHP) — used by all 3 CMOs

## 1. How GA requires prior authorization Georgia's Medicaid program requires prior authorization (PA) for a variety of services and drugs. Requirements vary by service category: - **Centralized (managed-care)**: Inpatient hospital admissions, outpatient hospital procedures, ambulatory surgical center (ASC) procedures, and certain behavioral-health services route through the **GAMMIS Centralized Prior Authorization Portal**, with criteria including medical necessity and step therapy where applicable. - **Fee-for-Service (FFS)**: A distinct set of PA requirements distributed across multiple **provider-specific manuals** (hospitals, DME, dialysis, behavioral health, etc.), each outlining documentation, applicable CPT/HCPCS codes, and effective dates. ## 2. How GA publishes and reports prior authorization Georgia uses a mix of centralized and decentralized systems: - **GAMMIS Centralized PA Portal**: Primary platform for managed-care PA submission (inpatient, outpatient, ASC, certain BH services). - **Provider-Specific Manuals**: Published on the GAMMIS Public Access portal (mmis.georgia.gov), categorized by provider type (hospital, DME, dialysis, podiatry, home health, hospice, telehealth, dental, etc.), each with documentation requirements, codes, and effective dates. - **Gainwell Technologies** operates the GAMMIS Public Access portal and supports reporting on PA requests/approvals/denials. ## 3. GA's CMS-0057-F and prior-authorization-reform compliance posture - **WISeR: Not applicable.** Georgia is **not** a WISeR (CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model) state. The six WISeR states are AZ, NJ, OH, OK, TX, WA. - **CMS-0057-F**: A federal interoperability/PA **rule** Georgia must align with. Georgia has **not** "submitted a CMS-0057-F application/waiver" (no such instrument exists — that claim was a synthesis fabrication). Georgia's posture is supported by its centralized GAMMIS portal (consistency/burden reduction) and detailed provider manuals (transparency). - **1115 Waiver**: Georgia Pathways to Coverage is the state's 1115 demonstration (a coverage/work-requirement demonstration; it is not the vehicle for CMS-0057-F alignment). - **Gold Card Law**: Georgia enacted gold-card legislation (per source documents; a specific bill number "SB 5" appears in the synthesis but is unverified — confirm against statute). ## 4. How GA runs its own program Georgia operates a hybrid managed-care + FFS model: ### Managed Care Organizations (MCOs) - Route PA through the GAMMIS Centralized PA Portal (inpatient, outpatient, ASC, certain BH). - Georgia Pathways to Coverage 1115 demonstration shapes coverage. ### Fee-for-Service (FFS) Providers - Provider-specific manuals on the GAMMIS Public Access portal define PA criteria, documentation, codes, and effective dates. ### Key Components - **GAMMIS Centralized PA Portal** (Gainwell-operated): single entry point for managed-care PA. - **Provider Manuals**: per-provider-type PA detail. Examples: inpatient hospital (medical necessity + step therapy), DME (medical necessity + step therapy + documentation), podiatry (non-healing wound + step-therapy failure documentation). ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Split architecture**: Centralized GAMMIS portal for managed-care PA + decentralized provider manuals for FFS — Georgia's defining structural feature. - **Gainwell-operated GAMMIS**: Single technology backbone for portal + public access + reporting. ### Missing/Uncertain: - **Some manuals lack criteria/codes**: e.g., Provider-Administered Drug List, compound-drug, telehealth-guidance documents omit specific PA criteria or step-therapy detail. - **Effective dates/revisions**: Inconsistent across documents. - **Gold Card bill number**: Unverified. - **CMS-0057-F**: Alignment ongoing; the "application" framing was incorrect and removed. Overall, Georgia runs a split prior-authorization architecture — a centralized GAMMIS portal for managed care plus per-provider-type FFS manuals — all on the Gainwell-operated GAMMIS backbone. Georgia is not a WISeR participant.