2940 Prescription / Medical Prior Approval (DMA)

Georgia State Seal

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Prescription / Medical Prior Approval (DMA)

Effective Date:

June 2020

Chapter:

2900

Policy Number:

2940

Previous Policy Number(s):

MT 27

Updated or Reviewed in MT:

MT-60

Requirements

A/Rs whose physicians have ordered more than the approved five prescriptions in a month may request approval from DMA for Medicaid to cover these extra prescriptions. Physicians or medical providers may also obtain prior approval from DMA for medical procedures, etc. DMA may approve or deny the request.

Basic Considerations

Although the process to get additional prescriptions/procedures covered by Medicaid is not an activity completed by eligibility workers, it is a question that is frequently asked of the Medicaid staff. Information on this process is contained in this section so that staff can inform A/Rs and providers on how to get additional prescriptions/procedures approved and also for emergency billing procedures.

Procedures

To request prior approval, the A/Rs physician or pharmacist is to follow the instructions provided in the DMA Provider Policy Manual, which may be found on the Georgia Medicaid Management Information System website at www.mmis.georgia.gov/portal/. An outline of the instructions follows.

Prior Approval

The physician/pharmacist requests DMA prior approval by calling (404) 298-1228 or toll free at (800) 766-4456. They can also access the web portal to do the prior approval or fax requests to (866) 483-1044 or mail to GHP, P.O. Box 7000, McRae, Georgia 31055. The written requests should be on the provider’s letterhead and include the following information:

  • Provider name

  • Provider number

  • Member name

  • Member ID number

  • Date of service

  • Procedure code and/or diagnosis code

  • Name and phone number of person to whom to return approval/disapproval notice.

Approval may be granted over the telephone or in writing. If the request is denied, the appeal process is explained at the time of the denial. The provider is responsible for the appeal process.

A prescriber may request a prescription prior approval review by simply providing the members' date of birth, name and Social Security Number (SSN) to the SXC Call Center Representative even if no active member ID exists. S/he is then assigned a member ID number which is valid for three to six months. When the member becomes active in GA Gateway, then the prescriber should again contact SXC to have the assigned member ID number merged with the new member ID number assigned when GA Gateway interfaced with MHN.

Emergency Billing

Emergency billing or prescribing is for emergency situations only. The physician or pharmacist is to follow the instructions in the DMA Provider Policy Manual. Providers having questions about emergency billing or prescribing should call DMA staff pharmacists at (404) 656-4044. A/Rs having questions about emergency procedures are to call CIC Member Inquiry at (866) 211-0950 or (770) 570-3373 in Atlanta area.