CareSource is one of the Georgia Medicaid care management organizations (CMOs) that administers the ABA benefit. Its ABA policy (MCD-MM-0212) is aligned to the Georgia DCH Part II ASD manual, but CareSource layers its own utilization-management process on top — so if a family carries CareSource, this is the guide that governs their authorization.
CareSource performs in-house prior authorization and medical review against the Georgia DCH ASD manual (its 7/1/2026 policy points to manual sections rather than restating them), and requires a Plan of Care signed by the BCBA and the parent/guardian with each medical-necessity review. Because it aligns to the DCH manual, the underlying clinical rules mirror Georgia Medicaid — but the submission path, forms, and timelines are CareSource's own.[1][3]
CareSource told Behavioral Health Business it had “recently notified certain providers in our Georgia network of adjustments to reimbursement for applied behavior analysis therapy services”; the reported term is 80% of the then-current Georgia Medicaid fee schedule from May 2026. The amendment went to providers individually and is not published, and neither edition of CareSource’s ABA policy mentions it, so confirm the rate in your own CareSource agreement before modelling revenue. It does not change coverage.[2][1][11]
The payment terms now sit in a policy nobody outside CareSource can read. The revision history of MCD-MM-0212 (effective 7/1/2026) says “Split payment info into PY-1634,” but as of October 18, 2026 PY-1634 is not on CareSource’s list of current Georgia Medicaid reimbursement policies, so its rules (rates, unit edits, modifiers) cannot be checked publicly. Ask CareSource provider services for a copy, and rely on your own CareSource letters for whether any 2026 rate change applies to your agreement.[2][1][11]
CareSource’s Georgia manual sets out the route. First enroll in Georgia Medicaid through GAMMIS; then ask CareSource for a contract with the New Health Partner Contract Form (CareSource.com, Providers, Tools & Resources, Forms, Georgia Medicaid) or by calling Provider Services at 1-855-202-1058. CareSource does no credentialing of its own: it accepts the decision of DCH’s centralized credentialing verification organization (CVO), which decides complete applications “within 51 calendar days.” CareSource “will not pay for claims for dates of service prior to the credentialing approval date.”[5][3]
Whether CareSource is taking new ABA groups right now is not published. The manual describes how to apply, not whether the network is open, so ask CareSource provider contracting. Individual practitioners must also meet DCH’s enrollment rules (Georgia licence and active BACB certification; the residence rule was dropped in October 2026).[5][3]
Georgia licenses the practice: “The unlicensed practice of applied behavior analysis is prohibited in this state,” at a fine of $1,000 per violation (O.C.G.A. 43-7A-6, added by HB 412, effective July 1, 2023). A BCBA “residing and practicing in another state who temporarily provides applied behavior analysis services in this state to a resident of this state” may apply for a temporary license covering “not more than a total of 30 days within a calendar year” (43-7A-8), and the board licenses by reciprocity someone actively licensed in a state with comparable requirements that reciprocates with Georgia (43-7A-9). As enacted, Chapter 7A contains no telehealth exception.[6][3][7]
Georgia Medicaid no longer has a residence test. The October 2026 ASD manual removed the requirement to live in Georgia or within 50 miles of its border (601.1.2); now “to enroll as a BCBA/BCBA-D Medicaid provider, practitioners must maintain an active certification issued by the BACB and hold a valid license from the Georgia Behavior Analyst Licensing Board.”[6][3][7]
Federal rules make the state Medicaid enrollment rule binding on the plan: the state “must screen and enroll, and periodically revalidate, all network providers” of Medicaid managed care plans (42 CFR 438.602(b)(1)). So a BCBA in CareSource’s network has to be enrolled with Georgia Medicaid as well.[6][3][7]
Within 30 days only. CareSource’s Georgia manual (DCH approved 7/22/2026): “Providers must submit a retro authorization within 30 calendar days of the service date, or discharge date for inpatient services where prior authorization was required but not obtained.” CareSource decides within 30 calendar days, and “Claims not meeting the requirement as described above will be administratively denied.” The manual still expects services that need authorization to be “authorized before the service is delivered.”[5]
Filing deadline: in-network claims “must be submitted within six months from the month in which the services were rendered.” CareSource’s claim-processing rules also allow “90 days from the EOP date to submit a clean claim,” and a corrected claim for incomplete or incorrect information may be sent within 180 calendar days of the date of service; corrected claims do not go through appeal. When CareSource is secondary, the provider “may submit for secondary payment within 90 calendar days of the primary carrier’s EOP, but not more than 12 months from the date of service or discharge.” Codes: MCD-MM-0212 says “the ASD Services Manual publishes applicable codes, modifiers and allowable provider types,” so CareSource bills ABA on the DCH ABS code set, CPT 97151–97158, 0362T and 0373T with the U1–U5 practitioner and U6/U7/GT setting modifiers; neither document lists an H-code for ABA. Payment: among its own obligations CareSource lists “Paying clean claims within 15 business days of receipt.”[1][3][5][8]
Taxonomy: CareSource matches each claim to the provider on three data elements — the NPI, the “billing taxonomy code, billing provider service location zip code +4 on file in CoreMMIS” — so the billing taxonomy on the claim has to match the provider’s GAMMIS record. On a CMS-1500 the rendering NPI goes in box 24J and the group NPI in box 33A.[1][3][5][8]
Disputes and appeals: a payment amount (underpayment or overpayment) goes through the claim payment dispute process, in writing “within three months of the date of payment”; CareSource decides within 15 calendar days. A denied claim goes in as a claim appeal within 30 calendar days of the date the adverse action, denial, remittance advice or initial review determination was mailed. A clinical appeal of a medical-necessity decision is due within 60 calendar days of the notice and needs the member’s written consent. Once CareSource’s process is exhausted, a provider may request an Administrative Law Hearing within 30 calendar days of the appeal decision (O.C.G.A. 49-4-153) or choose binding arbitration (O.C.G.A. 33-21A-7).[1][3][5][8]
Electronic Visit Verification does not reach ABA in Georgia. DCH’s EVV program covers Personal Support Services/Community Living Supports (T1019 and T1020) in the SOURCE, CCSP, NOW, COMP, ICWP and GAPP waivers, plus home health care (S5125 and S5126); ABA codes are not on the list. CareSource’s Georgia manual sets no EVV rule of its own.[1][3][5][8]
CareSource reviews the assessment PA in-house but takes its documentation list straight from DCH: MCD-MM-0212 (eff. 7/1/2026) says medical review "must be submitted with appropriate documentation as indicated by DCH's ASD Services Manual," and that the documentation for a behavioral assessment authorization "can be found in section 802 of the ASD Services Manual" — the diagnostic evaluation, Letter of Medical Necessity, IFSP if applicable, IEP (optional), prior hospitalization or placement records if applicable, the Medicaid Cover Page (Appendix D) and any other supporting clinical documentation. CareSource adds its own conditions: the diagnostic evaluation must be completed before the assessment review is requested, school psychoeducational assessments are not acceptable, the documentation should show member-specific symptoms rather than a repetition of DSM language, and a comprehensive behavioral assessment may not exceed 8 hours every 6 months without additional justification. To confirm the PA requirement for a code, CareSource's provider manual points to the Provider Portal's Prior Authorization procedure-code lookup.[1][5][3]
CareSource defers to the state list: “Documents to substantiate requests for review of medical necessity for follow-up services after an initial treatment PA can be found in section 803 of the ASD Services Manual.” That DCH section requires that progress and probe data “must not be more than two months older than the effective date of the requested prior authorization” and, since October 2026, skill-acquisition line graphs with continued requests. CareSource adds that a request after a temporary stop (summer break, a schedule change) is filed as a continuation, not an initial request, and that direct assessments for comprehensive, high-intensity services are updated with each plan of care.[1][3]
The questions that decide whether a family can start with CareSource (Georgia Medicaid CMO), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21, set by the state manual CareSource now points to. MCD-MM-0212 (eff. 7/1/2026) says eligibility conditions “can be located in section 701 of the ASD Services Manual,” and section 701 reads: “Autism Spectrum Services are for individuals under the age of 21.” The same section adds participation conditions that make caregiver availability an intake question: “children must be able to participate in sessions,” and members or caregivers “must be able to participate in ABS therapy and have the ability to implement ABS techniques in the home environment.” CareSource adds its own line: “Active parent/caregiver participation and involvement is required.”[1][3]
No fixed expiry. CareSource defers the re-evaluation triggers to the DCH manual and sets a floor for the re-evaluation itself: “At a minimum, 1 clinician observational assessment must reconfirm the diagnosis. School psychoeducation assessments are not acceptable.” The DCH triggers are a provisional diagnosis, no formal neuropsychological evaluation, or “more than 5 years from initial diagnosis and no evidence of ongoing assessment and treatment.” On the assessment side CareSource’s own cap is “Comprehensive BAs are not to exceed 8 hours every 6 months unless additional justification is provided”; under the DCH manual the behavioral assessment PA runs in 3-month increments and the assessment must be dated no more than 2 months before the treatment PA effective date. Diagnostic evaluations should be “completed prior to requesting a review of medical necessity for behavioral assessment or treatment services.”[1][3]
CareSource no longer restates the credential list: MCD-MM-0212 (eff. 7/1/2026) says evaluations “should meet requirements listed in section 801 of the ASD Services Manual” and “should be comprehensive with multiple informants covering multiple domains.” Section 801 sets the rule: the diagnosis must be established by “a licensed physician or psychologist, or other licensed professional as designated by the Medical Composite Board,” and the report must include “the evaluator’s signature, name, and credentials.” Primary hearing deficits, primary speech disorder and heavy metal poisoning must be ruled out as causal.[1][3]
Two tools, one from each side, per the DCH manual CareSource points to: a “minimum of two (2) assessment tools (1 primary clinician tool and 1 caregiver tool)” from the approved list, in a report that summarises each instrument with the date completed and scores — “test forms alone are not acceptable.” CARS and GARS cannot count as both the clinician and the caregiver tool. A diagnostic re-evaluation needs at minimum one clinician observational assessment, and school psychoeducational assessments are not acceptable (MCD-MM-0212).[1][3]
The state structure, administered in-house. Under the DCH manual “All ABS PAs must be requested by the enrolled QHCP,” and CareSource requires that “an independent practitioner must conduct a BA and develop a POC before services are provided,” with the treatment record signed by the BCBA and the parent/guardian and submitted “at the time the QHCP requests a medical necessity review for behavioral assessment or treatment services.” The clinical recommendation requirement underneath is the Georgia Medicaid one: 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 (42 CFR 440.130(c)), and the ordering, prescribing or referring practitioner’s NPI must be on the claim and enrolled in Georgia Medicaid.[1][3]
Allowed, with the state’s billing rules and a provider-judgement duty on top. MCD-MM-0212 (eff. 7/1/2026): “The ASD Services Manual publishes applicable codes, modifiers and allowable provider types. Additionally, Part II Policies and Procedures for Telehealth Guidance provides information for telehealth billing requirements, only billable if the provider is in GA or within 50 miles of the GA border when services are rendered. Telehealth services must be appropriate for the individual member and not used as the primary method of treatment.” Decisions must rest on current evidence and clinical consensus, weighing assessed needs, strengths, preferences and resources, with the same ethics as in-person care and attention to interstate licensure, state regulations and discomfort with technology; providers must have protocols for clinical appropriateness, such as risk assessment and safety planning. Under the DCH manual, a PA that requests telehealth for any code needs the Telehealth Readiness Checklist. On the claim, the DCH Telehealth Guidance that CareSource’s policy points to says “the GT modifier is required as applicable, and/or the use of either POS 02 or POS 10” (02 outside the home, 10 in the home), on top of the U1–U5 practitioner modifier; 97153 by telehealth is on DCH’s code table at the BCaBA and RBT levels as well as the analyst levels. 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.[1][4][3]
Ask the plan: The 50-mile clause specifically: DCH no longer has one anywhere. It added a Georgia-or-within-50-miles note to the ASD manual’s “Telemed” location code in July 2024 and removed it the same quarter, the October 2026 ASD manual removed the remaining enrollment residence rule (601.1.2), and DCH’s Telehealth Guidance (10/1/2026) does not state it. CareSource’s policy still does, so ask CareSource provider services whether it still applies the clause to claims.
CareSource's 2026 Georgia manual: "For standard prior authorization decisions, CareSource provides notice to the provider and member as expeditiously as the member's health condition requires, but no later than three business days after receipt of the request for service." "Urgent prior authorization decisions are made within 24 hours of receipt of the request for service." Either can be extended (14 calendar days for standard, 5 business days for expedited) if the member or provider asks, or CareSource justifies it to DCH. That is faster than the federal 7-calendar-day cap and Georgia's 7-day statute. Autism spectrum disorder PAs go through the GAMMIS centralized portal, not the CareSource portal. Timing for renewals, from the DCH ASD manual CareSource follows: treatment is authorized "in 6-month increments." The reassessment can be done once per 6-month period, "no more than 2 months prior to the effective date of the next treatment authorization." Its results must be “conducted/dated no more than two (2) months prior to the treatment services PA request effective date.” Schedule the reassessment inside that two-month window before the current authorization ends.[5][1][3][14][15]
CareSource follows "the federal regulations that Medicaid programs serve as the payer of last resort," and its ABA policy edition effective 1/1/2025 said: "When a member has other insurance, Medicaid is always the payer of last resort. CareSource will not pay more than the Medicaid rate totals for service. The primary payer must provide evidence of determinations for consideration of Medicaid coverage for services." The 7/1/2026 edition moved payment terms into a separate reimbursement policy (PY-1634) that is not publicly posted. Bill the commercial plan first. When CareSource is secondary, "the provider may submit for secondary payment within 90 calendar days of the primary carrier's EOP, but not more than 12 months from the date of service." A claim denied for missing COB information needs the primary EOB within the remaining timely-filing window. 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."[5][16][12][17][18]
Coverage decides whether CareSource (Georgia Medicaid CMO) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
CareSource defines supervision the DCH way — “the direct clinical review, for the purpose of training or teaching, by a physician, psychiatrist, BCBA-D, or BCBA” — and separates it from “direction,” the QHCP observing protocol implementation with the member and giving corrective feedback. It “reserves the right to request supervision documentation.” The rest is the DCH manual: supervision of non-enrolled practitioners follows BACB guidelines and “is not separately reimbursable as it is built into the direct service codes rates,” while direction may be billed as 97155; supervisor and supervisee each keep a contemporaneous record of every session; and since October 2026 DCH requires in-person supervision “at a frequency to ensure quality of the services being provided” (its former 10–20%-of-direct-hours supervision guide is gone). A physician, psychologist, BCBA-D or BCBA may supervise BCaBAs and RBTs; a BCaBA must be supervised by a physician, psychologist or BCBA/BCBA-D and may supervise RBTs.[1][3]
CareSource’s current policy is silent and defers to the DCH manual, which answers it: direction is billed as 97155 and “the technician’s time is separately reportable under 97153,” but “time reported and billed must be face-to-face time with the patient,” and 97155 documentation of “only supervision” or of services when the member is not present is not appropriate. 97154 and 97158 may not be billed concurrently. On other therapies, CareSource adds its own exclusion — MCD-MM-0212 does not cover "rehabilitative services or duplicative services for the provision of ABA" — and its Georgia provider manual says it "strives to follow the prevailing National Correct Coding Initiative (NCCI) edits as maintained by CMS". The DCH layer it defers to: 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.[1][3][5][12][13]
CareSource’s signature rule sits on the treatment record, not the daily note. MCD-MM-0212 (eff. 7/1/2026): the treatment record (plans of care, treatment plans, behavior support plans, functional assessments) “must be completed by the QHCP, signed by the BCBA and parent/ legal guardian (if minor age) or by the member, if applicable, and submitted to CareSource at the time the QHCP requests a medical necessity review.” The policy’s revision history records that the parent/guardian signature on daily progress notes before claims was removed on 3/12/2025. Daily notes follow the DCH manual: the RBT or BCaBA delivering the service completes and signs the daily session note under BCBA oversight; notes must be legible, complete, signed and dated with the actual date; rubber stamps are not accepted and secure electronic signatures are; records are kept in real time, never back-dated, and corrected by single strike-through with initials and date; since October 2026 DCH also requires each note within one business day of the service.[1][3]
MCD-MM-0212 (eff. 7/1/2026) describes ABA as provided “in centers or at home,” allows telehealth only when appropriate and “not used as the primary method of treatment,” and for school-based services notes that “DCH requires submission of a member’s IEP, IFSP or 504 if the provider is requesting school-based services,” pointing to section 804 of the DCH manual for school plans. Under that manual, school delivery needs a separate school plan alongside a home and/or clinic plan, and settings are billed U6 in-clinic, U7 out-of-clinic and GT telemedicine.[1][3]
CareSource defers to the DCH manual: for RBT- or BCaBA-rendered services such as 97153, “the supervising BCBA must be identified as the rendering provider on the claim,” and non-enrolled practitioners’ services are claimed under the enrolled provider number of the QHCP and/or facility. Multi-clinician practices enroll as a group, with each QHCP linked as a rendering provider.[1][3]
CareSource publishes no per-day unit ceiling of its own. MCD-MM-0212 (eff. 7/1/2026) says “Medical necessary will determine approved hours per week (eg, typically 10-30 hours)” and that “certain services may be allocated into 28-day periods and not eligible for carryover, even if an authorization is approved for 6 months.” Its payment terms moved to a separate reimbursement policy (PY-1634) that is not publicly posted. The DCH manual’s CMS daily maximums (97151 = 32, 97152 = 16, 97153 = 32, 97154 = 18, 97155 = 24, 97156–97158 = 16, 0362T = 16, 0373T = 32) are the state floor.[1][3]
Blocked on: CareSource reimbursement policy PY-1634 (Applied Behavior Analysis for Autism Spectrum Disorder – Reimbursement Policy) via CareSource GA provider services or the provider portal, for whether CareSource edits beyond the DCH daily maximums.
No H-code is published for ABA. CareSource's ABA policy points to the DCH ASD manual for codes and modifiers, and that manual's code set is CPT 97151–97158, 0362T and 0373T.
90 calendar days from the primary carrier's EOP, but no more than 12 months from the date of service.
Yes, through the DCH manual it follows: continued requests need skill-acquisition line graphs (since October 2026) and data no more than two months older than the requested effective date.
Yes — CareSource administers the Georgia Medicaid ABA benefit under policy MCD-MM-0212, aligned to the DCH ASD manual, with in-house prior authorization and medical review. Members must be under 21 with an ASD diagnosis.
CareSource says it notified certain Georgia ABA providers of reimbursement adjustments; the reported term is 80% of the Georgia Medicaid fee schedule from May 2026. The amendment is not published, so check your own CareSource agreement. Coverage is unchanged.
The clinical rules align to the DCH ASD manual, but CareSource runs its own PA/medical-review process and requires a Plan of Care signed by the BCBA and the parent/guardian with each review. Always confirm the member's plan at intake.
Enroll in Georgia Medicaid through GAMMIS, then request a CareSource contract (New Health Partner Contract Form or 1-855-202-1058). Credentialing is done by DCH’s centralized CVO, about 51 days for a complete application, and CareSource pays nothing before the approval date. CareSource does not publish whether its ABA network is open, so ask provider contracting.
Georgia prohibits unlicensed ABA practice (O.C.G.A. 43-7A-6); a temporary license of up to 30 days a year and reciprocity exist. To enroll in Georgia Medicaid a BCBA needs a Georgia license and active BACB certification; since October 2026 there is no requirement to live in Georgia or within 50 miles of its border.
Only if you request it within 30 calendar days of the service date; CareSource decides within 30 days and administratively denies late requests.
It is the ABA payment policy CareSource split out of its clinical policy: the revision history of MCD-MM-0212 (effective 7/1/2026) says “Split payment info into PY-1634.” As of October 18, 2026, PY-1634 is not on CareSource’s list of current Georgia Medicaid reimbursement policies, so its terms cannot be read publicly. Ask CareSource provider services for a copy, and check the rate in your own CareSource agreement.
Six months from the month the service was rendered, for in-network providers (CareSource Georgia provider manual). Corrected claims may be sent within 180 calendar days of the date of service, and the manual also allows 90 days from the EOP date to submit a clean claim.
Payment-amount disputes: in writing within three months of the payment date; CareSource decides within 15 calendar days. Denials: a claim appeal within 30 calendar days of the denial or remittance; medical-necessity appeals within 60 calendar days, with member consent. Then an Administrative Law Hearing request within 30 calendar days of the appeal decision, or binding arbitration.
The DCH Section 802 packet, which MCD-MM-0212 adopts by reference: diagnostic evaluation, Letter of Medical Necessity, IFSP if applicable, IEP (optional), prior hospitalization or placement records if applicable, the Medicaid Cover Page (Appendix D) and any other supporting clinical documentation. CareSource caps comprehensive behavioral assessments at 8 hours per 6 months without extra justification, rejects school psychoeducational evaluations as the diagnostic evaluation, and wants member-specific symptoms rather than DSM wording.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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