Amerigroup Georgia ABA coverage (GA Medicaid CMO).

Follows the Georgia Medicaid rule: Adaptive Behavior Services are an EPSDT benefit and “Autism Spectrum Services are for individuals under the age of 21.” Amerigroup’s UM Guideline CG-BEH-02 publishes no age criterion of its own — it is a medical-necessity guideline keyed to whether “a state mandate requires or a benefit plan explicitly provides coverage for ABT,” not an eligibility document.^[4][3]

Ask the plan: Note the vintage: the posted CG-BEH-02 is dated June 2018 (GAPEC-2437-18) and Amerigroup GA is operating under a DCH contract extension through 6/30/2027 — confirm the current guideline on the Amerigroup/Wellpoint provider portal.

Amerigroup publishes no window of its own — CG-BEH-02 requires a diagnosis of ASD and goals “based on standardized assessments” but names no recency rule, and the March 2026 Georgia Medicaid provider manual adds none — so the Georgia Medicaid rule governs. A diagnostic re-evaluation may be required when the diagnosis is provisional, when no formal neuropsychological evaluation was done, or when it is “more than 5 years from initial diagnosis and no evidence of ongoing assessment and treatment,” and the behavioral assessment “must have been conducted/dated no more than two (2) months prior to the Treatment PA effective date.”^[4][3][6]

The Georgia Medicaid rule governs. Amerigroup’s posted 2017 guideline CG-BEH-02 (no longer on its adopted Clinical UM Guidelines list, August 2026) was scope-of-practice based and deliberately broad: “a diagnosis of ASD has been made by a licensed medical professional or other qualified health care professional as is consistent with state licensing requirements.” The guideline separately required documentation “that ABT services will be delivered by an appropriate provider who is licensed or certified according to applicable state laws and benefit plan requirements.” The Georgia floor is narrower and governs for Medicaid members: the diagnosis must be established by a licensed physician or psychologist, or another licensed professional designated by the Medical Composite Board, and made by a practitioner enabled by the Georgia practice acts to diagnose behavioral health, intellectual or developmental conditions.^[3][4]

CG-BEH-02 names no instrument. It requires that “assessments of motor, language, social, and adaptive functions have been completed” and that treatment-plan goals be “in objective and measurable terms based on standardized assessments.” Which instruments qualify is left to the Georgia Medicaid rule, which governs Amerigroup members: at least two tools, “1 primary clinician tool and 1 caregiver tool,” from DCH’s approved list (for example ADOS-2 or CARS-2 plus ADI-R or SRS-2), and school psychoeducational assessments are not acceptable.^[3][4]

CG-BEH-02 is a medical-necessity guideline and states no referral gate, so the Georgia Medicaid structure governs: ASD services must be recommended by a licensed physician or other licensed practitioner of the healing arts acting within their scope of practice under state law per 42 CFR 440.130(c); all ABS prior authorizations must be requested by the enrolled QHCP (a licensed physician, psychologist, BCBA-D or BCBA — never a BCaBA or RBT); and the ordering, prescribing or referring practitioner’s NPI must appear on the CMS-1500 in box 17 with the DK, DN or DQ qualifier and be enrolled in Georgia Medicaid, or the claim denies. Assessment and treatment are authorized separately — assessment in three-month increments, treatment in six. Amerigroup adds a records rule of its own for behavioral-health services: its Behavioral Health addendum (November 2025) says “providers must submit a signed service order by an appropriately credentialed practitioner along with a comprehensive assessment” describing the member's physical and mental health status at admission to services; it does not say who counts as appropriately credentialed for ABA or how long the order stays valid.^[1][5][4][3]

CG-BEH-02 contains no telehealth provision, so the Georgia Medicaid floor governs: under the DCH Part II Telehealth Guidance (version date 10/1/2026), “practitioners of ASD services can use telehealth to assess, diagnose and provide therapies to patients,” and the guidance publishes the billable ABS telehealth codes — 97151–97158, 0362T and 0373T in 15-minute units with the GT modifier plus the U1–U5 practitioner-level modifier, on POS 02 (member outside the home) or POS 10 (member at home). Prior authorization applies to telehealth ABS exactly as in person. Assessment and supervision by telehealth follow the same state floor: 97151 and 97152 are on DCH's telehealth code table, and 97155 (protocol modification, the code that carries the analyst's direction of the technician) is on it at the U1–U3 levels only (physician, psychologist/BCBA-D, BCBA). DCH's ASD manual (October 2026) says supervision “does not require the supervisor to be present at the work site with the supervisee, but the provision of in-person supervision must be performed at a frequency to ensure quality of the services being provided” — some in-person supervision is expected, at no set share; supervision itself is built into the direct-service rates, and only direction billed as 97155 is paid.^[4][5][3]

Ask the plan: Amerigroup/Wellpoint Georgia provider services for any plan-level restriction the posted 2018 guideline would not show.

Amerigroup's Georgia Medicaid manual: "Amerigroup will decide on pre-service nonurgent care services within three business days from when we receive the request for service," and providers are notified through Availity or the MMIS portal in the same three business days. It may add 14 calendar days if the member or provider asks, or Amerigroup justifies needing more information to DCH. Expedited requests are decided "within 24 clock hours from when we receive the request for service," with notice "no later than 72 hours from the receipt of the request." The manual publishes no reauthorization lead time for ABA. Its 30-days-before-expiry renewal rule covers medical injectable and pharmacy PAs only. The ABA guideline expects the treatment plan to be updated and resubmitted "in general, every 6 months."^{[6][3][13][14]}

"Amerigroup agrees that the Medicaid program will be the payer of last resort when third-party resources are available." When it knows of other coverage before paying, Amerigroup will reject the claim and redirect "the provider to bill the appropriate insurance carrier." When it learns later, it recovers after payment. "State-specific guidelines will be followed when Coordination of Benefits (COB) procedures are necessary." For COB, "the time frames for filing a claim will begin on the date that the third party documents resolution of the claim." The manual publishes no pay-and-chase exception. 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."^{[6][11][15][16]}

The Georgia Medicaid rule applies, because Amerigroup publishes none of its own: neither CG-BEH-02, the Georgia Medicaid provider manual (March 2026) nor the Behavioral Health addendum (November 2025) sets a same-clock-time rule for 97153 with 97155. DCH's ASD manual allows concurrent billing for direction: when the analyst observes the technician and modifies or demonstrates a protocol, that time is billed as 97155 and “the technician's time is separately reportable under 97153,” face-to-face with the patient; 97154 and 97158 should not be billed concurrently, and when the analyst directs a technician-led group, 97154 and 97155 are reported together. Time that is only supervision, or that happens with the member absent, cannot be billed as 97155. On ABA alongside other therapies, CG-BEH-02 (reviewed 2017) has no billing rule; its Georgia Medicaid continuation criterion only stresses "the importance of coordinating ABS services with any other modality/service/therapy being received by the child at the same time." Under the DCH manual: ABA alongside speech, OT or PT — the Part II ASD manual sets no rule on ABA billed at the same clock time as another therapy. What it requires is coordination — the care plan must include "clear and specific coordination with all providers involved in the treatment of the individual" (602.3.2), treatment goals must "avoid duplication of other services" (Appendix F), the treatment-plan template asks for "Other Services (OT, SLP, PT, etc.)" and "Coordination of Care with Other Providers", and the required PA cover sheet (Appendix D) asks which private or school occupational, speech or physical therapy the member receives. On the claim, Part I §§209–210 apply the Medicaid NCCI edits "to services performed by the same provider for the same beneficiary on the same date of service"; in CMS's Medicaid practitioner PTP table active 10/1–12/31/2026, speech code 92507 bundles 97153–97157 and 0373T, 97153 bundles group speech 92508, and OT/PT code 97530 bundles 97153–97158 — all with modifier indicator 0, so one provider billing both on the same date loses the column-two line with no modifier override.^{[6][1][3][4][11][12]}

Ask the plan: Amerigroup/Wellpoint Georgia provider services, and the Georgia fee schedule inside GAMMIS.

The person who delivered the service signs. Amerigroup's Behavioral Health addendum (November 2025) lists what every progress note must carry: the member's correct name and ID, the correct code for the service and for the practitioner level, “beginning and ending time of the service,” total units, an intervention tied to a treatment-plan goal, a structured note format (BIRP, SOAP or similar), support for the units used, the “name, signature, and credentials of the person providing the service,” and “the date the note was signed (time and date stamped).” Treatment plans carry the signatures of the provider who completed them and of the member or family. The Georgia Medicaid floor adds the ABA specifics: for RBT- or BCaBA-rendered services such as 97153, “the RBT or BCaBA delivering the service is responsible for completing and signing the daily session or progress note,” and since October 2026 each note is due no later than one business day after the date of service.^[1][4]

Amerigroup publishes no place-of-service rule for ABA — neither CG-BEH-02 nor its Georgia Medicaid provider manual (March 2026) addresses setting — so the Georgia Medicaid rule applies: U6 in-clinic, U7 out-of-clinic (any location outside the agency or clinic), GT telemedicine. School delivery is allowed only under a separate school plan (target behaviors, line graphs, a titration plan, and the IEP, IFSP or 504 plan for a public-school student) that sits alongside a home and/or clinic plan.^[4][6][3]

Amerigroup sets no rule of its own, so the Georgia Medicaid rule applies: for RBT- or BCaBA-rendered services such as 97153, “the supervising BCBA must be identified as the rendering provider on the claim”; BCaBAs and RBTs are not enrolled as providers, and their services are claimed under the enrolled QHCP’s and/or facility’s provider number, with the U1–U5 practitioner-level modifier and the U6/U7/GT setting modifier. Multi-clinician practices enroll as a group, with each QHCP linked as a rendering provider.^[4][6][3]

Unconfirmed for the current contract. Amerigroup’s posted UM Guideline CG-BEH-02 (current effective date 9/27/2017, last review 8/3/2017) set a supervision ceiling: “Up to two (2) hours of protocol modification will be covered for every ten (10) hours of direct ABT therapy. Any greater frequency of protocol modification will require written documentation demonstrating the need for additional protocol modification.” But CG-BEH-02 is not on Amerigroup’s current list of Clinical UM Guidelines adopted for Georgia Medicaid members (August 2026), whose only BEH entries are CG-BEH-14 and CG-BEH-15, so do not budget 97155 against that 20% figure without confirming it. The Georgia Medicaid floor sets no percentage: supervision follows BACB rules, and the October 2026 treatment-plan template says protocol modification “should be commensurate with the member's clinical needs and treatment complexity.”^[3][2][4]

Blocked on: AGPAutism@amerigroup.com or Amerigroup Georgia provider services: ask which ABA criteria replaced CG-BEH-02 and whether any protocol-modification ratio applies beyond the DCH manual.

Amerigroup gates by the week, not the day. “The total hours of ABT requested should be comprised of fewer than 40 hours per week” — more than 40 requires documentation of why, because “ABT services for more than 40 hours per week have not been shown to be more effective.” Group adaptive behavior treatment and social-skills group hours count inside that 40. Exposure adaptive behavior treatment and exposure treatment with protocol modification (0362T/0373T) “should be comprised of fewer than 10 hours per week.” No per-code per-day unit ceiling is published. Those limits come from the 2017 guideline, which is not on Amerigroup’s current adopted Clinical UM Guidelines list (August 2026), so treat them as unconfirmed; the Georgia Medicaid floor is the ASD manual’s Appendix A daily maximums (97151 = 32, 97152 = 16, 97153 = 32, 97154 = 18, 97155 = 24, 97156–97158 = 16, 0362T = 16, 0373T = 32 units), with requests over 30 hours a week getting an enhanced review.^[3][2][4]

Blocked on: AGPAutism@amerigroup.com or Amerigroup Georgia provider services: ask whether any weekly-hour or per-day unit limit applies beyond the DCH Appendix A daily maximums.