Medicaid requirements

Georgia Medicaid program

In Georgia, the Medicaid Program is a jointly administered federal/state program that provides medical benefits to low-income individuals and families. Georgia’s Medicaid program is administered by the Georgia Department of Community Health (DCH).

Several programs comprise Georgia’s Medicaid program. A brief overview of the relevant programs is included below, but for more information on additional programs and requirements, visit medicaid.georgia.gov/programs.

• Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) pays for private, employer- sponsored health insurance coverage for Medicaid members under the age of 19.
• Georgia Families^® is a statewide program designed to deliver health care services to members of Medicaid, PeachCare for Kids^®, and Planning for Healthy Babies^® (P4HB) recipients. Children, parent/caretaker with children, pregnant women and women with breast or cervical cancer on Medicaid, as well as children enrolled in PeachCare for Kids^® are eligible to participate in Georgia Families.
• PeachCare for Kids^® provides comprehensive coverage to uninsured children.

 

Managed care plans

As a Georgia provider, you are an in-network provider for members enrolled in the following managed care plans:

• CareSource

 

Medicaid enrollment

To provide routine vision care services to Georgia Medicaid members, you must enroll with both programs:

1. Georgia Medicaid. You can enroll and check your application status via the Georgia Medicaid Management Information System (GAMMIS) enrollment wizard. You must ensure your Medicaid registration (type 1 NPI, type 2 NPI, location affiliations) matches how you plan to submit claims to EyeMed.
2. EyeMed Vision Care^®. You can enroll with us by completing a New Provider Application, and entering “Georgia Medicaid” in the notes section. Typical turnaround time is 10 business days.

 

Provider requirements

In-network Medicaid providers must:

• Review and meet all requirements outlined in the EyeMed Georgia Medicaid Provider Manual (requires inFocus login to access), including some that are unique to this plan.
• Provide both exams and materials to Medicaid members.

 

Medicaid lab

You have the option to use the EyeMed lab network or a lab of your choice for Georgia Medicaid members. If you use EyeMed’s lab network, you must use Classic Optical.

Medicaid frame selection

If you don’t use the EyeMed lab network, Medicaid members may choose from a selection of frames you offer instead of the Medicaid-approved frame collection. You must be able to dispense standard size frames at no cost to the member.

If you use EyeMed’s lab network, you must register in EyeMed’s online claims system with Classic Optical. Once registered, you’ll receive a frame kit with a selection of frames available to members. Members must choose from the frame collection. NOTE: You will only receive a frame kit if you don’t already have one in your dispensary.

• The collection is for display and try-on use only.
• Do not send frames from the kit to the lab.
• If a frame manufacturer discontinues production of a frame that is listed as a benefit, you may use the discontinued frame from your sample kit.

You should also have available, or be able to order, frames for infants or those with allergies to frame materials and other special needs.

Submitting claims and ordering glasses

If you use the EyeMed lab network:

• Register for Classic Optical in our online claims system and search for labs listed as Medicaid in the “services provided” field. Refer to the Registering for a Medicaid lab job aid for step-by-step instructions.
• Follow our normal lab ordering process using our online claims system.
  • You must select the correct job type and indicate the reason for any medically necessary lenses.
  • Refer to the Filing claims for Medicaid job aid for step-by-step instructions.

Refer to the Claims codes section in the EyeMed Georgia Medicaid Provider Manual for detailed instructions. You must be logged into your account on inFocus to access the manual.

 

Coordination of Benefits (COB)

Details for how the COB process is administered in the state of Georgia can be found in the EyeMed Georgia Medicaid Provider Manual. You must be logged into your account on inFocus to access the manual.

Medicaid coordination of benefits

• Primary payer. Medicaid is considered the payer of last resort.
  • Federal regulations require you to bill all identifiable financial resources available for payment, including Medicare, prior to billing Medicaid.
• Submitting COB claims. File COB claims in hard copy using a CMS 1500 form. You must attach a copy of the primary plan’s explanation of benefits/remittance advice. Refer to the submitting claims section below for more information.

TPL guidance

If you find:	Then a case member may be eligible for:
A case member is over 65 or blind or disabled	Medicare and Medicare supplemental policies
A case member, absent parent, stepparent, dependent child, new spouse of an absent parent, or anyone else who is legally or voluntarily responsible for a case member is EMPLOYED or UNION MEMBER	Employment-related health insurance
A case member, spouse of a case member, absent parent or stepparent is ACTIVE-DUTY MILITARY or a VETERAN	Military health insurance for active duty, retired military and their dependents coverage
A case member has been in an accident or otherwise accidentally injured: INJURY/TRAUMA/ACCIDENT	Workman’s compensation Homeowner’s insurance Automobile insurance Liability insurance

 

Related provider resources Provider Manual – Georgia Medicaid Registering for Medicaid network labs Filing claims for Medicaid Medically Necessary Contact Lens Form – Georgia Medicaid