Appendix C Medicaid Issuance | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Medicaid Issuance

Effective Date:

October 2022

Chapter:

Appendix C

Policy Number:

Appendix C

Previous Policy Number(s):

MT 64

Updated or Reviewed in MT:

MT-67

Requirements

Medicaid cards are issued to individuals eligible for Medicaid only benefits. Recipients present the cards to Medicaid providers to verify Medicaid eligibility.

Medicaid providers should confirm Medicaid eligibility at each visit via the Interactive Voice Response system (IVR) or GAMMIS web portal.

Basic Considerations

Medicaid eligibility determined by DFCS, is transmitted to the Department of Community Health (DCH) through interfaces.

Medicaid Cards

Upon approval of a Medicaid application, verification of eligibility for each member is included in the approval notice generated by the DFCS eligibility system and sent to the Head of Household (HOH). Thereafter, DCH issues each Medicaid eligible member a onetime Medicaid ID card to be used when the member wishes to obtain Medicaid services. The member’s eligibility or ineligibility and any limitations associated with a particular COA under which eligibility is determined is reflected to the provider when the Medicaid eligibility is verified via the IVR or the GAMMIS web portal.

Certain Medicaid recipients are not issued or reissued a Medicaid card. Members who will not receive cards are those approved for:

SLMB
QI-1
QDWI
EMA under any COA
Retroactive eligibility under any COA
No reissuance of a Medicaid card if not eligible in current month
Hospice if no “Lock In” received from the Hospice provider

Medicaid eligibility in DCH’s computer system, Georgia Medicaid Management Information System (GAMMIS), may be viewed at www.mmis.georgia.gov by the member and by DFCS staff, if proper id and password have been provided.

The Gainwell Technologies Member Contact Center will be available by phone Monday through Friday (excluding state holidays) from 7am to 7pm at 770-325-2331 local or toll free outside the metro area at 1-866-211-0950.

Members may also confirm eligibility in GAMMIS by calling the Gainwell Technologies Member Contact Center and accessing the Interactive Voice Response system (IVR) at 1-866-211-0950.

The Gainwell Technologies Provider Contact Center is available to providers by phone Monday through Friday (excluding state holidays) from 7am to 7pm at 770-325-9600 local or toll free outside the metro area at 1-800-766-4456.

Providers may call the Gainwell Technologies Provider Contact Center to access the IVR at 1-800-766-4456. The IVR is operational 24 hours a day, seven days a week. Callers who prefer speaking with a person may opt out of the IVR once it is accessed. Providers may verify pharmacy eligibility by calling Optum Rx at 1-800-766-4456. For clinical-prior authorization support, call 1-866-525-5827. Members eligible for SLMB, QI-1 or QDWI only will be shown as ineligible on the web portal and IVR.

DCH performs nightly card runs to issue cards to newly eligible members and to members who have reported lost or undelivered cards. Members enrolled in a CMO will have their Medicaid card mailed from the assigned CMO only. Recipients should not expect the Medicaid card for seven to ten days from date of Medicaid approval or request for replacement card. Replacement cards will not be issued to A/Rs who are not eligible in the month of request or who were not to be issued a card as outlined on page 1. Also, replacement Medicaid cards cannot be ordered through the GAMMIS system for members enrolled in a CMO.

Medicaid cards are mailed to the residential or mailing address provided to DCH by SSA or DFCS through computer system interfaces.

Medicaid cards that cannot be delivered to the HOH are returned to the facility in Tucker, Georgia. Members who need a replacement card should notify the Member Contact Center to update the address and reissue the card. If the member is enrolled in a CMO, they should contact their CMO for a replacement card. The member should also notify DFCS of any change in address to be changed in Gateway. Gateway data is the source data and will override what is manually changed in GAMMIS. Thus, if the address is changed in GAMMIS, but not in Gateway, the problem will reoccur. DCH is responsible for verifying Medicaid eligibility for all Georgia Medicaid members for Medicaid providers.

Medicaid Identification Numbers

A 9-digit client ID number is assigned by Gateway and passed to DCH via the interface. GAMMIS assigns a 12-digit Medicaid number. Numbers issued prior to 11/1/10 will start with '111', numbers issued after 11/1/10 will start with '222'. A Medicaid provider should be able to file Medicaid claims by using DCH’s 12-digit number. SSI recipients may use their 9-digit Social Security Number plus an “S” (i.e.,123456789S) or the 12-digit GAMMIS number.

Other Medicaid Eligibility Forms

Other Medicaid eligibility forms are issued to the member in the following situations:

Form 962, Certification of Medicaid Eligibility, when medical services are needed prior to the time a Medicaid card is issued by DCH, when the member requests verification of retroactive Medicaid, or eligibility cannot be entered in Gateway (Refer to Chart C.1). The DFCS worker uploads a copy of Form 962 to GAMMIS Web Portal at www.mmis.georgia.gov. The Form 962 revised 07/2021 is used for both current and historical months. Please refer to the MA SharePoint for most current version of Form 962.

Form 962 should never be issued for QMB, SLMB, QI-1, or QDWI recipients
Form DMA 632 (Presumptive Pregnant Women), and 632H, (Hospital Presumptive Eligibility), is issued by the Public Health Department and certain “qualified Providers”, and a copy is forwarded to DFCS/RSM. The presumptive Medicaid number is used by the member until such time a plastic Medicaid card is mailed.
Form DMA 632W (Eligibility Determination for Women’s Health Medicaid Program) is issued by the Public Health departments and its designated partner providers. A copy is forwarded to the local RSM worker. This certification form entitles women, who have been diagnosed with breast or cervical cancer, to all Medicaid covered services

Procedures

Non-Emergency Situations

Form 962 or other historical database corrections should be uploaded to GAMMIS Web Portal at www.mmis.georgia.gov. Please refer to the MA SharePoint for Instructions for Uploading 962’s.

For newly approved/recertified SSI clients, upload the SSI Certification Letter to the GAMMIS Web Portal at www.mmis.georgia.gov. Optum Rx will be updated for prescriptions via the GAMMIS interface.

Existing/ongoing SSI clients should report changes/corrections through the Member Contact Center by accessing the Interactive Voice Response system (IVR) at 1-866-211-0950.

GAMMIS and Optum Rx will be updated with eligibility via the interface.

Emergency Situations

For newly approved SSI clients complete the following:

Upload the SSI Certification letter to the GAMMIS Web Portal at www.mmis.georgia.gov.
In the event of an emergency call the Member Contact Center using the dedicated DFCS line at 1-877-512-3130 (ask for Member Enrollment) to have the client added to GAMMIS. Please inform the Member Enrollment agent if prescriptions are needed.

For emergency prescriptions or other COAs with prescription problems, complete the following:

Verify in GAMMIS that the customer is showing active. Use either the web portal or IVR. If A/R is not showing eligible in GAMMIS, send the emergency request to membernotification@dch.ga.gov.

Prior Approval and Emergency Doctor’s Visits

For out-of-state providers rendering emergency services, providers follow Policies and Procedures for Hospital Services, Section 909 as found on the GAMMIS web portal, Provider’s Manuals.

Out-of-State Providers and Service Limitations: Out-of-State hospital providers not enrolled in the Georgia Medicaid program as participating providers will be reimbursed for covered services provided to eligible Georgia members while out-of-state if the claim is received within twelve months from the month of services, and if at least one of the following conditions is met:

The service was prior authorized by the Division, OR
The service was provided as a result of an emergency or life-endangering situation occurring out-of-state. (If the out-of-state provider believes the medical record supports the existence of an emergency situation but the diagnosis does not justify an emergency, the claim must be submitted with a copy of the medical record.)

Providers can obtain more information regarding filing claims, or other questions at www.mmis.georgia.gov.

For physicians to have procedures prior approved, they should submit the Prior Authorization via the GAMMIS web portal.

In situations where A/Rs have used all of their allotted twelve doctors' appointments and who now need another doctor’s visit, the doctor will need to file the claim manually and write on the top of the form that this is an emergency doctor visit and explain the nature of the emergency.

Georgia Families

Georgia Families is a partnership between the Department of Community Health (DCH) and Care Management Organizations (CMOs) to expand managed care in Georgia and promote increased access to and utilization of primary and preventative care. The Department of Community Health has contracted with three CMOs to provide these services throughout the state. They are:

Amerigroup 800-600-4441
www.amerigroup.com/medicaid

Peach State Health Plan 800-704-1484
www.pshpgeorgia.com

CareSource 855-202-0729
www.caresource.com

Members can contact Georgia Families for assistance to determine which program best fits their family’s needs. If members do not select a plan, Georgia Families will select a health plan for them.

Members can visit the Georgia Families Website at www.georgia-families.com or call 1-800-GA-ENROLL (1-888-423-6765) to speak to a representative who can give them information about the CMOs and the health care providers.

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.

Enrollment in a (CMO) is a requirement for recipients in the following programs:

Parent/Caretaker Medicaid
Pregnant Woman Medicaid
Child Under 19 Medicaid
PeachCare for Kids®
Women’s Health Medicaid
Transitional Medical Assistance
Planning for Healthy Babies

The following recipients are not required to enroll in a CMO:

People who need special medical services or live in an institution
People on Medicaid who qualify for Medicare
People on Medicaid that are government approved as part of an Indian tribe
People who qualify for Supplemental Security Income (SSI)
Children in the Children’s Medical Services Program
Children in the Georgia Pediatric Program
Children with care coordination by the Multi-Agency Team for Children (MATCH) program
People in Long Term Care
People in the Service Options Using Resources in Community Environments (SOURCE) program
People in Pre-Admission Screening and Resident Review
People receiving Hospice Care
People who get Health Insurance Premium Payments (HIPP)

CMO Issues

CMO issues that an A/R is unable to resolve by contacting the individual CMO should be forwarded to the Regional Medicaid Field Program Specialist, who will then route to the State Office for resolution.

Use the following chart to determine when Medicaid cards will be issued by DCH/and when DFCS should issue Medicaid authorization forms.

Chart C.1 - Issuance of Form 962, Certification of Medicaid Eligibility
IF	THEN
A newly eligible SSI recipient requires medical services prior to receiving his/her first Medicaid card from DCH Non-emergency	Advise the recipient to obtain a “Certification for SSI Eligibility Form” from SSA, AND once received in the county DFCS office, complete and issue a Form 962 to the recipient for the current month only, AND Upload a copy of the Certification for SSI Eligibility Letter to GAMMIS Web Portal at www.mmis.georgia.gov. OptumRX will be updated via the GAMMIS interface regarding prescriptions.
A newly eligible SSI recipient requires medical services prior to receiving his/her first Medicaid card from DCH Emergency	Advise the recipient to obtain a “Certification for SSI Eligibility Form” from SSA, AND Once received in the county DFCS office, complete and issue a Form 962 to the recipient for the current month only, AND County designee should telephone the dedicated DFCS line to the Member Contact Center at 1-877-512-3130 to add eligibility to GAMMIS, AND Upload a copy of the Certification for SSI Eligibility Letter to GAMMIS Web Portal at www.mmis.georgia.gov, AND If recipient needs emergency prescriptions, inform Gainwell Technologies member enrollment agent during update.
An eligible Georgia SSI recipient Life Threatening	Advise the recipient to obtain a “Certification for SSI Eligibility Form” from SSA, AND Once received in the county DFCS office, complete and issue a Form 962 to the recipient for the current month only, AND County designee should telephone the dedicated DFCS line to the Member Contact Center at 1-877-512-3130 to add eligibility to GAMMIS, AND Upload a copy of the Certification for SSI Eligibility Letter to GAMMIS Web Portal at www.mmis.georgia.gov, AND Add a note to the 962 if prescriptions are needed for a life-threatening situation.
An SSI recipient from another state moves to Georgia AND continues to be eligible for Medicaid through SSI in Georgia AND Needs medical services the month of move	Advise the recipient to obtain a “Certification for SSI Eligibility Form” from SSA, AND Once received in the county DFCS office complete and issue a Form 962 to the recipient for the current month only, AND Request county designee to notify CIC by telephone 1-866-211-0950 that Form 962 is being issued, AND Upload a copy of the Certification for SSI Eligibility Letter to GAMMIS Web Portal at www.mmis.georgia.gov. AND If recipient needs emergency prescriptions, include a note on the 962.
A newly eligible Gateway A/R needs medical care or prescriptions before GAMMIS and Optum can update eligibility	Check GAMMIS for eligibility AND Upload Form 962 to GAMMIS Web Portal at www.mmis.georgia.gov for eligibility update and include case notes for the request
Other situations	Other than the situations mentioned above, it is appropriate to upload a Form 962 for an A/R ONLY* in situations in which it is not possible to enter information into Gateway. These are: Any month(s) over 13 months prior to current month An AMN spenddown month which needs to have the first day liability amount decreased or the begin authorization date earlier than is shown in Gateway. *Form 962 should NEVER be given to providers, Nursing Homes, Cost Recovery agency, etc.

Please see next page for a Claims or Billing issue cheat sheet.

Other Considerations

You have a Claims or Billing Issue?

The Department of Community Health contracts with DFCS to perform correct eligibility determinations and to insure those are transmitted correctly to the GAMMIS Web Portal. When you are contacted with a claims or billing issue, you should:

Check whether all months of eligibility are correct on Gateway, including any LA-D issues such as facility, patient liability, etc. If not, correct all months in Gateway. If so, proceed to your next step.
Check whether all months are correct on the GAMMIS Web Portal. If not, FAX a 962 for correction to Gainwell Technologies Member Contact Center at 1-866-483-1045. Enter case notes in Gateway for any actions that cannot be corrected in the system
If Gateway and GAMMIS are correct, you have no recourse to find a solution for the provider or member. At this point we need to make referrals to Gainwell Technologies or DCH if the Gainwell Technologies referral is not successful.

For Providers: All providers should have a policy manual regarding their billing and claims. They also have access to information including banner messages on www.mmis.georgia.gov.

Gainwell Technologies Provider Voice Response System: 1-800-766-4456
Gainwell Technologies Contact Us: www.mmis.georgia.gov

For Hospice Providers: Form for election/discharge/revocation/transfer are faxed to 1-866-483-1045, ATTN: Member Enrollment. Providers should follow up with their field representatives whenever there is a problem, with proof of their submission. Member enrollment is allowed 7 to 10 business days for this update from date of receipt.

For Members: Member information (non-eligibility specific) is found on www.mmis.georgia.gov
Gainwell Technologies Member Contact Center: 1-866-211-0950

DCH contact numbers are available on their website under Contact Us at dch.georgia.gov. This is available to the public, providers, and members.

Problem Resolution

Requests for manual updates that cannot be done via Gateway must be faxed to 1-866-483-1045.

Please allow 3-5 business days for Gainwell Technologies to update the information.

If there is not a timely response, please forward the issue through the appropriate chain of command within your office before using the emergent needs procedures below.

DCH has established a group email distribution list that will be monitored several times a day, for emergency issues only. This email address is membernotification@dch.ga.gov. Please use this email for the following escalated or emergent issues:

Member approved in Gateway but not showing on the portal and the member has a medical emergency
Name misspelling/DOB/SSN mismatch, and if it is an emergency which prevents the member from receiving services.
Duplicate ID’s
Twins – only one showing up on the portal even though both are in Gateway
Child put under wrong mother due to similar name or
DOB with another child
Optum Rx pharmacy updates/issues
Buy-In request (problem issues not resolvable through Gainwell Technologies-use the Word buy-in form but send to the DCH address listed above.

Buy-in inquiries and buy-in data corrections should be faxed to the Gainwell Technologies Buy-In Unit at 1-866-483-1045. Workers should use the Buy-In template that is available in Appendix F. Gainwell will send written response to DFCS of the action taken on the inquiry/discrepancy.