Georgia Medicaid ABA coverage: the intake guide.

The treatment PA package

Diagnostic evaluation, Letter of Medical Necessity, descriptive behavioral-assessment results, proposed Plan of Care (with coordination of other services), updated data and progress summaries on renewals, IFSP if applicable, IEP optional (required for school-based services), prior hospitalization or out-of-home placement records if applicable, the Telehealth Readiness Checklist if telehealth is requested, and the DCH Medicaid cover page (Appendix D).^{[2][4][5][19][12][20][21]}

Assessment recency

The behavioral assessment must be dated no more than 2 months before the treatment PA effective date. A diagnostic evaluation Medicaid did not pay for is still accepted. The 8-hours-per-6-months cap on comprehensive assessments is CareSource's rule (MCD-MM-0212), not a DCH one.^{[2][4][5][19][12][20][21]}

Reauthorization every 6 months

Requires a behavior assessment conducted within 2 months of the requested effective date, progress vs. prior goals (skill-acquisition line graphs are required for continued requests since October 2026), and updated individualized goals.^{[2][4][5][19][12][20][21]}

Does the assessment PA take longer?

No separate or longer decision clock is published for the assessment. The same clock governs every PA request: 7 calendar days for fee-for-service members (42 CFR 440.230(e), from 1/1/2026), and three business days in all three CMO manuals (extendable by 14 calendar days). What makes the start feel slow is the sequence: the assessment and treatment are "completed separately and authorized independently" (Peach State GA.CP.BH.504), so a new client needs two PAs back to back, assessment PA, then the assessment, then the treatment PA. DCH's ASD manual lets the behavioral assessment PA be requested "in 3-month increments", and requires the assessment to be dated no more than 2 months before the treatment PA effective date, so do not let a finished assessment sit.^{[2][4][5][19][12][20][21]}

Under 21. The current DCH ASD manual (version date October 1, 2026) states it under General Eligibility: “Autism Spectrum Services are for individuals under the age of 21,” and the benefit is assessment and treatment “provided to Medicaid beneficiaries in accordance with the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Benefit and according to medical necessity.” Four further conditions sit alongside the age bound: Medicaid must be active on each date of service; “children must be able to participate in sessions”; the member “must exhibit behaviors that present as clinically significant health or safety risks to self or others or are behaviors that are significantly interfering with basic selfcare, communication, or social skills”; and members or caregivers “must be able to participate in ABS therapy and have the ability to implement ABS techniques in the home environment as instructed by their behavior analyst.”^[2]

Three clocks, none of them a fixed expiry on the diagnosis itself. Re-diagnosis: “a diagnostic re-evaluation to re-confirm diagnosis may be required” when the diagnosis is provisional, when “no formal neuropsychological evaluation was completed/conducted,” or when it is “more than 5 years from initial diagnosis and no evidence of ongoing assessment and treatment”; the re-evaluation “must include, at a minimum, 1 clinician observational assessment.” Behavioral assessment: it “must have been conducted/dated no more than two (2) months prior to the Treatment PA effective date,” and follow-up treatment PAs need “the results of a recent Behavioral Assessment (within 2 months).” Data: progress and probe data on a continued-treatment request “must not be more than two months older than the effective date of the requested prior authorization.” A diagnostic evaluation Medicaid did not pay for is accepted, and the manual puts no age limit on it.^[2]

Credential: “a documented diagnosis of ASD must be established by a licensed physician or psychologist, or other licensed professional as designated by the Medical Composite Board prior to completing a PA for Behavioral Assessment or Treatment Services,” and “the diagnosis must be made by a practitioner enabled by the OCGA practice acts to diagnose behavioral health/intellectual/developmental conditions.” The evaluation report must summarise each instrument, give the date completed with the tests administered and scores, and carry “the evaluator’s signature, name, and credentials” — “test forms alone are not acceptable.” Primary hearing deficits, primary speech disorder and heavy metal poisoning must be ruled out as causal. The October 2026 manual no longer carries the one-year ASD-experience requirement on the diagnostician that the January 2018 edition imposed.^[2]

Two tools, one from each side, and it is now the state rule rather than a CMO one: a “minimum of two (2) assessment tools (1 primary clinician tool and 1 caregiver tool)” from DCH’s approved list, in an evaluation that uses “valid and reliable evaluation tools that conform to industry standards and include direct observation, parent/caregiver interviews, and standardized tools for the diagnosis of autism.” Clinician tools include ADOS-2, GARS-3, CARS-2 ST/HF, STAT, CSBS, TELE-ASD-PEDS, NODA, DISCO, RITA-T, ADEC, EarliPoint and Canvas Dx; caregiver tools include ADI-R, DISCO, CARS-QPC, GARS-3, SCQ, M-CHAT, SRS-2, ASRS, ABC and TASI, plus non-ASD-specific tools such as BASC, PDD-BI, PEDS:DM, ASQ-3, ASQ:SE2, CBRS, CDI and the CSBS-DP Infant-Toddler Checklist. CARS and GARS cannot count twice: using the clinician and caregiver versions of the same scale “requires a separate acceptable caregiver or clinician tool.” “School psychoeducational assessments are not acceptable for diagnostic evaluations.”^[2]

Two separate gates, and only one of them is what intake usually means by “referral.” Clinically, 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), and “all ABS PAs must be requested by the enrolled QHCP” — a licensed physician, psychologist, BCBA-D or BCBA; BCaBAs and RBTs cannot serve as the QHCP. Administratively, the ordering, prescribing or referring practitioner’s NPI must appear on the claim — on the CMS-1500 “enter qualifiers to indicate if the claim has an ordering, prescribing, or referring provider to the left of the dotted line in box 17 (Ordering = DK; Referring = DN or Supervising = DQ)” — and that practitioner must be enrolled in Georgia Medicaid, or the claim denies. The treatment PA package also carries the IFSP/IEP where applicable.^[10][2]

Georgia publishes a real telehealth benefit for ABS, set out in the DCH Part II Telehealth Guidance (version date 10/1/2026), which carries its own ASD section. “Practitioners of ASD services can use telehealth to assess, diagnose and provide therapies to patients,” provided they hold a current Georgia medical or psychology licence or a valid ABA certification; Georgia Medicaid enrols BCBAs as QHCPs for this purpose. The guidance publishes a Category I code table for telehealth ABS — 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T, each in 15-minute units with the GT modifier and the U1–U5 practitioner-level modifier (U1 physician/psychiatrist, U2 psychologist or BCBA-D, U3 BCBA, U4 BCaBA, U5 RBT). On the claim, “the GT modifier is required as applicable, and/or the use of either POS 02 or POS 10,” where POS 02 is telehealth outside the patient’s home and POS 10 is telehealth in the patient’s home; CPT modifier 93 may be appended for audio-only services where appropriate. Prior authorization applies to telehealth ABS exactly as it does in person, and the ASD manual (October 2026) adds a front-end step: “The Telehealth Readiness Checklist (located in Appendix D) must be completed for all services delivered via telehealth and submitted as supporting documentation with the prior authorization (PA) request” — the General Telehealth Readiness section plus the section for each CPT code requested. The member and/or caregiver “must be able to actively participate in treatment activities,” and “providers conducting more than 25% of assessments via telehealth and/or 50% of units of service via telehealth are subject to an increased frequency of audits” (section 903.3, added October 2026). Assessment and supervision by telehealth: the assessment codes 97151 and 97152 (and 0362T) are on the telehealth code table, so the initial behavior identification assessment and reassessments may be delivered remotely under the same PA; 97155 (protocol modification, the code that carries the analyst's direction of the technician) is on the table only at the U1–U3 levels (physician, psychologist/BCBA-D, BCBA), as are 97156–97158. For supervision itself, the ASD manual 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; it is not separately billable, and only direction billed as 97155 is paid. One caution on money: the telehealth guidance’s own code table still prints rates below the ASD manual’s Appendix A (for example 97153 at U5 GT $15.13 against $15.58), because DCH raised Appendix A on 10/8/2025 — bill from Appendix A. There is no 50-mile rule any more: DCH 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, and the October 2026 manual also removed the enrollment requirement to live in Georgia or within 50 miles of its border (601.1.2).^[10][2]

Federal law sets the ceiling, and Georgia's CMOs publish a faster clock. For fee-for-service members, the state must decide a standard prior authorization "in no case later than 7 calendar days after receiving the request" (beginning January 1, 2026). It may add up to 14 calendar days if the family or provider asks or the state needs more information. Expedited requests are due "no later than 72 hours." CMO members fall under the federal managed-care cap of 7 calendar days from receipt (42 CFR 438.210(d)), plus Georgia's prior-authorization law. That law applies to DCH's CMO contracts (O.C.G.A. 33-46-30): notice "within 7 calendar days of obtaining all necessary information," 72 hours for urgent, and "automatic authorization" when a deadline is missed. All three CMOs' current manuals print a stricter standard: three business days for a standard request and 24 hours for an expedited one. For fee-for-service ABS, DCH's ASD manual (October 2026) tells providers to "allow up to 7 calendar days for the PA request to be reviewed and a decision issued," plus 10 more calendar days when supplemental documentation is sent to cure a technical or peer denial. Treatment PAs run in six-month increments and assessment PAs in three-month increments. Reauthorization lead time: requests "may be submitted up to 2 months before the PA's effective date," the reassessment may be done no more than 2 months before the next treatment period starts, and an effective date may be set up to 30 days before submission but never backdated further.^{[19][23][12][20][21][24][2]}

Georgia Medicaid pays last. DCH's Part I manual (version date July 1, 2026): "other available third-party resources must be exhausted before Medicaid/PeachCare for Kids pays." Providers must file "with the appropriate primary health plan(s) prior to filing with Medicaid" and list the other insurers and their payments on the claim. Medicaid pays only the gap up to its own maximum allowable. 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." A claim the primary plan denied because the provider did not follow its rules is not paid: DCH "will not reimburse the provider submitted charges denied by the primary plan because of the provider's failure to follow the primary plan's rules." So get the commercial PA as well. A service the primary plan does not cover, or where its annual or lifetime limits are exhausted, "is reimbursable up to the Medicaid/PeachCare for Kids maximum allowable amount." EPSDT exception: "A provider is not required to exhaust other health plan benefits with respect to claims for preventive and pediatric services including health check (also known as EPSDT)." The manual does not say whether ABS claims fall under it. 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."^{[13][25][26][27][28]}

Ask the plan: The member's CMO or the GAMMIS TPL unit (678-564-1162, option 3) — ask whether an ABS claim for a child under 21 is paid under the EPSDT exception without the primary EOB.

Georgia leaves the ratio to the BACB and, since October 2026, publishes no supervision percentage. “Supervision” is direct clinical review for training or teaching by a physician, psychiatrist, BCBA-D or BCBA and “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”; supervisor and supervisee must each keep “a contemporaneous record of the date, duration, type, and brief summary of the pertinent activity for each supervision session,” producible on audit. Supervision of non-enrolled practitioners “must be performed in accordance with the supervision guidelines of the Behavior Analyst Certification Board and this policy manual,” and it “is not separately reimbursable as it is built into the direct service codes rates; however, ‘direction’ may be separately reimbursable” (as 97155). The October 2026 treatment-plan template dropped DCH’s former 10–20%-of-direct-hours supervision guide; it now says protocol modification “should be commensurate with the member's clinical needs and treatment complexity,” and a request for more needs documentation supporting medical necessity. Who supervises whom: physicians, psychologists, BCBA-Ds and BCBAs may supervise BCaBAs and RBTs; a BCaBA must be supervised by a physician, psychologist or BCBA/BCBA-D and may supervise RBTs; an RBT is supervised by a BCBA/BCBA-D or BCaBA and can never be the QHCP. The October 2026 manual no longer carries the six-supervisee caseload cap or the staffing attestation form of the 2018 edition.^[2]

Yes, for direction. The manual defines “direction” as the QHP observing the technician implement the patient’s protocols and giving feedback, or demonstrating a new or modified protocol, and says it “should be reported and billed using code 97155… The technician’s time is separately reportable under 97153… Time reported and billed must be face-to-face time with the patient.” The limits: for 97155, “documentation of only supervision or documentation of services being performed at a time when the member is not present would not be appropriate,” and “97154 and 97158 should not be billed concurrently” — when the analyst joins a technician-led group to direct it, 97154 and 97155 are reported together; 97158 is for groups the analyst leads. 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.^[2][13][22]

Georgia publishes a per-code daily ceiling in Appendix A of the ASD manual, headed “Daily Max Units per Procedure code as Mandated by CMS, effective 7/1/2021”: 97151 = 32, 97152 = 16, 97153 = 32, 97154 = 18, 97155 = 24, 97156 = 16, 97157 = 16, 97158 = 16, 0362T = 16, 0373T = 32 (15-minute units). Weekly intensity is set by the PA: treatment “typically range[s] from 10 to 30 hours per week,” and “requests exceeding 30 hours per week will undergo an enhanced authorization review.” Group sessions billed as 97154 need at least two and no more than eight participants.^[2]

Whoever delivered the service writes and signs the note. 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, with clinical oversight provided by the supervising BCBA in accordance with BACB requirements.” Records must contain “progress notes that are legible, detailed, complete, signed and dated”; every signature must be “legible, original and belong to the person creating the signature” (with the name printed if illegible) and dated the actual date signed; rubber stamps are not accepted, and “Secure Electronic Signatures are acceptable” only as the Part I manual defines them. Records are documented in ‘real time’ and not back-dated; corrections take a single strike-through plus the corrector’s initials and date, never whiteout. Since October 2026 (602.3.3) every note must be completed “no later than one (1) business day following the date of service,” never backdated or “copied from previous sessions without revision,” and must identify the member, date of service, service location, start and stop times, CPT code billed, and provider name and credentials; the manual adds sample RBT and BCBA note templates. “Unless otherwise specified, progress notes do not need to be submitted with routine prior authorization requests.” The treatment plan carries the supervising BCBA/BCBA-D’s signature.^[2]

Georgia prices by setting and regulates school delivery. Every ABS line carries a location modifier — U6 in-clinic, U7 out-of-clinic (“billable for delivery of ASD services in any location outside of your agency/clinic,” at a higher rate), GT telemedicine — alongside the practitioner-level modifier. School delivery is allowed but gated: a separate school plan is required “for all educational settings to include both public and private schools” (daycares and after-school programs only when services are provided under IDEA), with operationally defined target behaviors, behavior-reduction line graphs, a titration plan for fading school services, and the IEP, IFSP or 504 plan for a public-school student (not required for a member in private school or homeschool). School plans “should be accompanied with a treatment plan for services to also occur in either the home and/or clinic setting,” because treatment at school is limited to reducing problem behavior that blocks academic work; school-only services are an individual exception. Training school personnel is reimbursable only with the parent or guardian present, in person or virtually. The manual sets no group-home rule.^[2]

Group enrollment, with the supervising BCBA as the rendering provider for technician time. Practices that submit professional claims and have two or more individuals “must enroll as a group,” and physicians, psychologists, BCBA-Ds and BCBAs “must enroll as rendering providers linked to the group or facility.” “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 directly by the Division as providers because they are not considered independent practitioners,” and their services are claimed under the enrolled provider number of the QHCP and/or facility. There is no grace period: “Services delivered by individuals who are not fully credentialed or not enrolled in the Medical Assistance program are not billable.” To enroll: “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.” The October 2026 manual removed the former requirement to live in Georgia or within 50 miles of its border. Practitioner level rides as a modifier (U1 physician/psychiatrist, U2 psychologist or BCBA-D, U3 BCBA, U4 BCaBA, U5 RBT) plus the setting modifier (U6/U7/GT). The ordering, prescribing or referring practitioner’s NPI must be on the claim (CMS-1500 box 17: DK ordering, DN referring, DQ supervising) and enrolled in Georgia Medicaid, or the claim is denied.^[2]