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Medical Billing Services in Georgia

Most Georgia Medicaid and PeachCare for Kids members are served by private care management organizations rather than the state directly, Georgia runs its own Pathways coverage program, and workers' comp and surprise-bill disputes each have a state process of their own. We bill remotely for Georgia practices and set each one up separately.

  • Georgia Families CMO claims for Medicaid and PeachCare for Kids members
  • Workers' comp priced against the State Board's fee schedules
  • Out-of-network disputes taken through the state arbitration process
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Insurance oversight and surprise-bill arbitration in Georgia

Georgia's Office of the Commissioner of Insurance and Safety Fire licenses and regulates insurance companies and reviews health insurance policy forms used in the state. Its Surprise Billing Consumer Protection Act (HB 888) sets up a process, run through the Commissioner's office, for settling payment disagreements between insurers and providers outside their networks.

Official sources: Georgia Office of the Commissioner of Insurance and Safety Fire (external site), Georgia OCI: surprise billing rules and regulations (external site)

Georgia Families, care management organizations and Pathways

Georgia Families delivers care to Medicaid and PeachCare for Kids members through private care management organizations (CMOs) working in partnership with the Department of Community Health (DCH). Most Georgia Medicaid members are enrolled with a CMO rather than in fee-for-service Medicaid. The plans in the program can change through state procurement, so we confirm the current CMOs rather than list them.

Georgia Pathways to Coverage offers health coverage to residents who are not otherwise eligible for traditional Medicaid and meet program requirements, including reporting qualifying activity hours. Because eligibility depends on meeting program requirements, we check Pathways coverage before each visit.

Official sources: Georgia Medicaid: Georgia Families (external site), Georgia DCH: Medicaid managed care (external site), Georgia Pathways to Coverage (external site)

Practices we typically see in Georgia

Georgia practices that see Medicaid and PeachCare for Kids patients mostly bill a CMO, not DCH directly, because most members are in Georgia Families plans. That usually means credentialing and contracting with each CMO the practice wants to work with.

How remote billing works for practices in Georgia

We work remotely in your systems and the CMO and payer portals. Your practice sets up our access and can change it whenever it needs to.

  1. Step 1: Confirm each patient's CMO

    Medicaid and PeachCare members are matched to their current care management organization at scheduling.

  2. Step 2: Check Pathways eligibility

    Coverage is re-checked for Pathways members before each visit, since eligibility depends on program requirements.

  3. Step 3: Price work injuries to the Board schedule

    Workers' comp claims are compared with the State Board's current fee schedules.

  4. Step 4: File out-of-network disputes

    Qualifying out-of-network payment disputes are prepared for the state process under the Surprise Billing Consumer Protection Act.

Workers' compensation fee schedules in Georgia

The Georgia State Board of Workers' Compensation adopts medical and dental fee schedules for workers' comp claims, and the schedules are made available for purchase through FAIR Health. Schedules are revised over time, so we work from the Board's current version.

Official source: Georgia State Board of Workers' Compensation: medical and dental fee schedules (external site)

Official sources for Georgia

Rules change. These are the agencies and contractors we check for the current requirements.

Frequently asked questions

Which Medicare contractor handles Georgia?

Palmetto GBA, the Medicare Administrative Contractor for Jurisdiction J, which also covers Alabama and Tennessee.

Official source: CMS: A/B MAC Jurisdiction J (Palmetto GBA) (external site)

Do we bill the state or a plan for Georgia Medicaid patients?

Usually a plan. Most members are enrolled with a care management organization under Georgia Families, so claims go to the patient's CMO.

Official source: Georgia DCH: Medicaid managed care (external site)

What is Georgia Pathways to Coverage?

A program offering coverage to residents who are not otherwise eligible for traditional Medicaid and meet its requirements, including reporting qualifying activity hours.

Official source: Georgia Pathways to Coverage (external site)

How are out-of-network payment disputes resolved in Georgia?

Through the process set up under the Surprise Billing Consumer Protection Act, administered through the Insurance Commissioner's office.

Official source: Georgia OCI: surprise billing rules and regulations (external site)

Can a remote team credential us with Georgia CMOs?

CMO credentialing and contracting are done through applications and portals, so the work does not depend on location. Credentialing with Georgia CMOs can be included in your engagement.

Related services and nearby states

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See how your Georgia CMO claims are performing

A free audit groups your Medicaid denials by CMO and checks eligibility, credentialing and out-of-network payment issues.

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