Author: SHP Staff

Medicaid Phased Roll-Out of Centralized Prior Authorization Portal Launches on June 1, 2013!

Georgia’s Department of Community Health (DCH) is beginning the implementation of a phased centralized prior authorization function for traditional Medicaid and the three CMOs (Amerigroup, Peach State Health Plan and WellCare). This centralized PA will be available on the Georgia Medicaid Management Information Services (GAMMIS) web portal at

The centralization of the PA process will be phased in for the CMOs; beginning with Pregnancy and Newborn Delivery Notifications on June 1, 2013. There will be no change in the prior authorizations requested for traditional Medicaid beneficiaries; however, CMO participating providers can now use the traditional Medicaid system to submit prior authorizations for the services identified below in Phase 1. In the traditional Medicaid portal, the prior authorization screen will be updated to include a field that allows you to choose either traditional Fee for Service Medicaid, Amerigroup, Peach State or WellCare.

Phase 1

6.1.2013: Newborn & Delivery Notification Forms will be completed and submitted via the Centralized PA Portal Functionality

7.1.2013: The following will be moved to the Centralized PA Portal:

1. PAs for the following Place of Services (POS) should be entered through the Centralized PA Portal:

21-Inpatient Hospital Services

22-Outpatient Hospital Services

24-Ambulatory Surgery Services

2. In State Transplants

3. Hospital Outpatient Therapy

4. Appeals & Reconsiderations Request

5. Submissions of initial and additional clinical data attachments


Exclusions During Phase 1 (Do Not Submit These PA Types During Phase 1): Services handled by CMO Third Party Vendors (dental, vision, radiology, etc) & Behavioral Health Inpatient or Outpatient PAs

Once the PA requests are submitted through the centralized portal, they will be routed to the applicable CMO for review and approval/denial. PA requests will generate a GMCF Tracking ID once submitted; this is not the Prior Authorization Number used for CMO claims submissions.

 1. If the PA is approved by the CM< the CMO’s assigned authorization number will be displayed in the “Vendor Authorization ID” field with a Status of “Approved” and this number should be used on the claim.

2. If the PA is denied, a CMO assigned reference number will be displayed in the “Vendor Authorization ID” field with a Status of “Denied” and this number should be used for reconsiderations/appeals.

3. If the PA is in process, the CMO will display a status of “Pending”.


It is anticipated that additional service categories will be added to the Centralized PA functionality after the initial Phase 1 Roll-Out. Additionally, through the centralized PA portal, PA requests may be submitted a maximum of 30 days prior to elective service/admission and retrospective PA requests may only be submitted if the service/admission was emergent.


As this centralized PA function is implemented, SHP believes that it is critical for our clients to track whether the PA process time frame is significantly delayed by the centralization function in order to communicate those concerns back to the Department of Community Health (DCH).


DCH Requirements for Ordering, Prescribing, Referring Physicians To Take Effect on 7.1.2013

The Affordable Care Act (ACA) requires that all physicians or other practitioners who prescribe or order services for Medicaid recipients or who refer Medicaid recipients will have to be enrolled as a Medicaid provider. Services that are rendered based on a referral, order or prescription will be reimbursed only if the ordering, referring or prescribing physician/practitioner is enrolled in the Georgia Medicaid program. The Department of Community Health had announced that Hewlett Packard would begin accepting applications from OPR providers on April 1, 2013 and that the full requirement will take affect for all claims with DOS on July 1, 2013 and later.

DCH has also published an FAQ on the new requirements for Ordering, Referring and Prescribing providers which can be accessed at the following link:


SHP wants to highlight the following FAQs that were included in DCH’s posting:


1. Referrals, Orders & Prescriptions from Out-of-State Providers:

Federal law requires all OPR physicians or other professionals rendering services under the State Plan to be enrolled as providers. The provider that ordered, prescribed, or referred the services must be enrolled in the Medicaid program in which the beneficiary is eligible, in this case Georgia Medicaid. The NPI of the out-of-state OPR provider must be included on the claim for payment to the provider rendering the services ordered, prescribed, or referred. Therefore, a provider outside Georgia who orders, prescribes, or refers services must be enrolled in the Georgia Medicaid program for Georgia Medicaid to pay the claim of the participating provider who actually renders the service. This includes physicians or other professionals employed at hospitals or other health care facilities.


2. CMO Claims (Amerigroup, Peach State Health Plan & WellCare):

This new OPR requirement does not apply to orders, prescriptions or referrals for individuals enrolled in a Medicaid CMO. It is applicable only to the Georgia Fee for Service (FFS) Medicaid Program.


3. How will you be able to tell if an OPR provider is enrolled in Georgia Medicaid:

The Georgia Medicaid Management Information System (GAMMIS) Web Portal at will have a search capability so individuals and entities will be able to determine if an OPR provider is enrolled in Georgia Medicaid.

As a reminder, If you are already enrolled as a Medicaid provider, you do not need to also enroll as a Medicaid OPR provider.

However, it will be critical to ensure that when you perform services for Medicaid patients that were ordered, prescribed or referred by another practitioner, that the other practitioner is enrolled as an active or OPR Medicaid practitioner.


Qualifying for the Medicaid Primary Care Increases for 2013 and 2014

Pursuant to the Affordable Care Act, physicians who provide a majority of primary care services to Medicaid beneficiaries are eligible to receive increased reimbursement on these services for their Medicaid beneficiaries for 2013 and 2014. The Department of Community Health (DCH) is tasked with managing the administration of these increases and have just announced the final process for eligible physicians to attest that they qualify for these increased payments. Based on DCH’s final publication, the categories for qualifying for the Medicaid increases has widened; therefore, SHP encourages our clients to review the following categories to determine if you will qualify.


Physicians can qualify for the incentives in one of two ways:

1. Be Board certified (ABMS, ABPS, or AOA certifications accepted) in the following specialty or sub-specialty:

Adolescent Medicine Pediatric Internal Medicine

Allergy and Immunology Internal Medicine

Cardiology Internal Medicine Critical Care

Cardiovascular Disease Neonatology

Critical Care Medicine Neonatal-Perinatal Medicine

Diabetes Nephrology

Emergency Medicine Oncology

Endocrinology Pediatrics

Family Practice Pediatric Allergy

Family Practice Geriatric Medicine Pediatric Developmental & Behavior

Gastroenterology Pediatric Emergency Medicine

Geriatrics Pediatric Endocrinology

Hematology Pediatric Gastroenterology

Hematology/Oncology Pediatric Hematology/Oncology

Infectious Disease Pediatric Infectious Disease


2. For the most recent calendar year (2012), attest that 60% of your services to Medicaid beneficiaries have been either E&Ms or Vaccine Administration Codes.

If you will qualify, please see the notification below that was published by DCH as a guide to the attestation process, which opened on 5.1.2013 and will remain open for 90 days:

On May 1, 2013, currently enrolled and future Georgia Medicaid Provider’s will be able to utilize the Georgia Health Partnership Web Portal (located at to submit the ACA Rate Increase Attestation or Board Certification. The ACA Rate Increase Attestation will also be available on paper for currently enrolled providers to submit and included in the paper enrollment applications for new providers enrolling in Georgia Medicaid for the first time.


There are three ACA Rate Increase Attestations:

Medical Billing

The Medical Billing Attestation should be submitted if the provider is not board certified by the American Board of Physician Specialties (ABPS), the American Osteopathic Association (AOA) or the American Board of Medical Specialties (ABMS) only and at least 60% of their total Medicaid billings are E & M and/or vaccine administration codes.

Board Certification

The Board Certification Attestation should be submitted if the provider is a physician and is board certified by the Board of Physician Specialties (ABPS), the American Osteopathic Association (AOA) or the American Board of Medical Specialties (ABMS) only.

Non-Physician Practitioner

The Non-Physician Practitioner Attestation should be submitted by an Advance Nurse Practitioner, a Physician Assistant or a Nurse Mid-Wife or a Physician who supervises an Advance Nurse Practitioner, a Physician Assistant or a Nurse Mid-Wife who wishes to receive the ACA Rate Increase. An Advance Nurse Practitioner, a Physician Assistant or a Nurse Mid-Wife must be supervised by an enrolled Georgia Medicaid provider. Please note, the Advance Nurse Practitioner, a Physician Assistant or a Nurse Mid-Wife must list the physician’s active Georgia Medicaid provider ID# on either the paper or web portal attestation. The Physician will also have to list the Advance Nurse Practitioner, a Physician Assistant or a Nurse Mid-Wife’s active Georgia Medicaid provider ID# on either the paper or web portal attestation.

Provider’s who are currently enrolled in Georgia Medicaid, can either submit the paper attestation or log into the secure side of the MMIS web portal using their username and password. The Provider Rate Increase request panel will be located under the Provider Enrollment – Provider Rate Increase Request link on the MMIS web portal; you will attest either board certified or medical billing. If you choose board certified, you will be able to upload the applicable board certification listed above with the submitted attestation.


Provider’s who are new applicants will be able to attest either by the paper enrollment application or on the MMIS web portal via the web application. New applicants who are board certified will need to submit the applicable board certification with either application. The paper attestations will be available on the MMIS website,, under the Provider Information, forms, enrollment drop-down box.



CMS Announces Sequester Reductions to Medicare EHR Incentive Program

The mandatory sequester or reductions in federal spending mandated by the Budget Control Act of 2011 continue to roll out.  CMS has published an update concerning the mandated reductions to the Medicare EHR Incentive Program.  Under the sequester, the Medicare EHR incentive payments to eligible physicians and hospitals will be reduced by 2%.  This reduction will be applied to any Medicare EHR Incentive Payment that  has a reporting period that ends on or after April 1, 2013.  If the final day of your EHR incentive reporting period occurs before April 1, 2013, your incentive payment will not be subjected to the mandatory 2% reduction.

 Also, please note that all Medicaid programs were specifically excluded from the mandatory cuts required by sequestration; therefore, the Medicaid EHR Incentive Program will not be affected.

 For CMS’ full announcement, please visit the link below:

If you have any questions, please contact SHP.

Update to Health Check Services for Georgia Medicaid

On 4.1.2013, Georgia Medicaid posted the provider notice below regarding an update to their Health Check (EPSDT) services. The notice provides guidance on billing vaccine administration codes along with the necessary modifiers in conjunction with Health Check services.  Please note that DCH indicates that “health check providers may adjust or resubmit immunization claims for dates of service on or after January 1, 2013, in order to receive the vaccine administration fee for vaccines administered on or after January 1, 2013…”


Once DCH publishes any update or change to traditional Medicaid, the CMOs generally have 45 days to implement into their own systems.


Dear EPSDT Providers:

Effective April 1, 2013, the Diphtheria and Tetanus toxoids (DT) vaccine (CPT code 90702) is no longer reimbursed under the Health Check program.

Beginning April 1, 2013, providers should bill any and all of the following appropriate vaccine administration codes, when administering VFC vaccines to children 18 years of age and younger, as they apply: 90460, 90471, 90472, 90473, 90474. The ICD-9 diagnosis code v20.2 may be used when vaccines are administered during the Health Check visit. Additional details regarding the vaccine administration codes and reimbursement are contained in Appendix C of the EPSDT (Health Check Services) Manual, updated April 2013.

Beginning May 1, 2013, Health Check providers may bill the Health Check program for vaccines administered to members nineteen (19) years of age through twenty (20) years of age. Include the vaccine CPT and diagnosis codes along with a vaccine administration code on the Health Check claim. This means that the ‘EP’` modifier must be used with all codes so that our MMIS recognizes the claim as a Health Check claim. The Division will reimburse providers for the vaccine product (providers must use their own stock of vaccines) and for each vaccine administered at a rate of $10 per vaccine administered. Health Check providers may adjust or resubmit immunization claims for dates of service on or after January 1, 2013, in order to receive the vaccine administration fee for vaccines administered on or after January 1, 2013, however, the appropriate vaccine administration code must be included on the claim.

Providers will be notified when the ACA increased rates are applied, and the rates will be retroactive to January 1, 2013.

Senates Spending Plan Keeps Medicare Cuts from Sequestration

Yesterday, the Senate passed a spending plan package to prevent the scheduled federal government shutdown scheduled for March 27, 2013. The spending package will keep the government financed to run through September 1, 2013 and now goes to the House for passage.

As reported by Modern Healthcare in the article below, the Senate spending package maintains many of the healthcare cuts included in the government sequester, including the 2% reduction to Medicare Part A and Part B claims for dates of service on and after April 1, 2013. As a reminder, this 2% cut is applied after any member cost sharing for services is applied rather than applied to the Medicare allowable for services.

Please see the article below for full details about the Senate spending package and how it addresses the sequester’s cuts to the healthcare industry:


Pace of Medicare Spending is Slowing

The White House has just released the annual Economic Report of the President; which featured an interesting graph detailing the projected amount that Medicare spending will account for in the total GDP between 2013 and 2085.

Based on the rate of growth in Medicare spending prior to 2009, estimates had indicated that Medicare spending would outpace the economy and  eventually account for 7% of the total GDP by 2085.  However, from 2009-present, the actual rate of Medicare spending has slowed considerably and is now growing at the same rate as the economy. 

As discussed in the article, there is uncertainty about whether this slowdown in spending is solely attributable to the economic recession.  However, the report presents some data that could indicate the slowdown in spending is a result of other factors, such as a decrease in hospital readmissions.

If this trend continues where the growth in Medicare spending remains consistent with the growth of the total economy, it could significantly re-orient the conversation about federal spending on healthcare.

CMS News Regarding Mandatory Reductions to MPFS through Sequestration

As mandated by prior federal legislation, mandatory cuts in federal spending were enacted through sequestration on March 1, 2013. The sequestration cuts will impact the Medicare fee for service fee schedule, effective for claims with dates of service of April 1, 2013 and later. Cahaba GBA has posted the notification below communication that the sequestration cuts will include a 2% reduction to the Medicare fee for service schedule (Parts A and B).

There has been conversation about how the 2% reduction would be applied. Based on our understanding, the reduction will be applied after any member cost-sharing (co-pay or deductible) has been applied. For example, if Medicare traditionally allows $100 for a service, the following will occur:

Claims with DOS of March 31, 2013 or earlier:

Allowable: $100.00

Deductible: $20.00

Payment by Medicare: $80.00


Claims with DOS of April 1, 2013 and later:

Allowable: $100.00

Deductible: $20.00

Payment by Medicare (taking the 2% reduction): $78.40


Health Insurance Exchange Products

As we move closer to the rollout of the health insurance exchanges, health insurance carriers are beginning to prepare their product offerings to offer either within the health insurance exchange or as a competitive product to the health insurance exchange products. The following article from the Wall Street Journal discussed how health insurers are developing lower premium products that feature a narrower network of providers:

While the article focuses primarily on hospitals; the insurers’ push to develop these products will affect all healthcare providers. As noted in the article, when beneficiaries are comparing and selecting a health plan, “The tests have found that premiums are the most important factor in consumers’ choices, he said, with more than half typically opting for a narrow-network product if it cost them at least 10% less than an equivalent with broader choice.” Therefore, insurers are incentivized to develop these lower-premium, narrow networks to appeal to consumers purchasing healthcare coverage through the exchange.

To achieve the necessary savings to offer reduced premium products, insurers are pushing for rate reductions from healthcare providers. As stated in the article above, “WellPoint Inc. has said it is aiming to pay providers somewhere between Medicaid and Medicare rates, and sees talks trending toward rates close to Medicare.. An Aetna Inc. official at an investor conference Monday suggested the rates might settle somewhere between Medicare and commercial.”

The insurers are positing that although the rates will be lower for providers, there will be more patients driven into their practice through these health insurance exchange products. This is unlikely to true; for example, in Georgia, it has been estimated that 2/3 of the beneficiaries purchasing insurance coverage through the exchange will be moving from a commercial insurance product to a health exchange product. Based on this estimate, there is a significant possibility that by participating in a reduced-rate, narrow provider network for the health exchange, you may reprice your current commercially insured patients to rates somewhere between Medicare/Medicaid.

Additionally, while insurers are pushing for significant rate reductions from physicians, it is unlikely that there will be any correlation between the amount that your rates are reduced and the actual premium reductions that insurers will offer on their exchange products. As noted above, as little as a 10% difference in premium will make a difference to a consumer and insurers are discussing rate reductions of much greater than 10% for providers.

When looking at the insurers’ strategy in developing health insurance premiums, it is also important to remember that under healthcare reform, they are required to meet specific medical loss ratios, which sets specific guidelines about how premium dollars can be spent. Depending on the size of the health plan, between 80% and 85% percent of all premium dollars must be spent directly on healthcare services; however, between 80% and 85% of $2 million premium dollars is significantly more than 80%-85% of $1 million premium dollars. Health insurers are effectively incentivized to maintain higher premium rates.

SHP will continue to monitor these market developments but strongly believes that you need to be cautious in looking at any new healthcare product that will be offered on the exchange. Insurers are going to tell you about all the patients that you are going to lose by not accepting their terms for their exchange products but their efforts to drastically reduce your rates while minimally lowering their premiums has the potential to be one of the biggest gimmicks in the healthcare market and can significantly affect your practice.


SHP can help with your ACO!

SHP is excited to announce that we now provide both consultation and management services for primary care providers who are interested in forming an  ACO (Accountable Care Organization). Based on the continuing market transition under healthcare reform, SHP strongly believes that primary care physicians have a unique opportunity to move from generating their revenue solely from patient care to a combination of patient care and shared savings and that this transition will continue to encourage long-term viability and success.


Our ACO services include education and engagement, feasibility analysis, development of ACO quality criteria, partner selection (capitalization and administration), and market selection as well as ongoing ACO management. SHP will be hosting events over the coming weeks to discuss the new ACO opportunities for primary care physicians across Georgia, South Carolina, and Alabama.