MedicaidDocumentationHigh impact
[Georgia] Prepay Auditing Update
CareSource·GA · Psychiatry, Speech Therapy, Physical Therapy +2 more·Provider Bulletin
Effective date
Apr 3, 2026
We identified it
May 9, 2026
Summary
CareSource Georgia Medicaid is implementing prepay claims auditing effective April 3, 2026, requiring submission of medical records to support coding compliance with CMS, AMA, and AHA guidelines. Claims flagged with reason codes BB1 or PJR require medical record documentation within 30 days or will remain denied for up to 365 days; denials are not guaranteed payment and are subject to dispute rights.
Action Required
By April 3, 2026: Billing team must prepare for prepay medical record audits by: (1) Training all coders and billing staff on documentation requirements outlined in the policy table (treatment plans, signed orders, consent forms, progress notes, diagnostic reports, operative reports, and proof of delivery as applicable by service type); (2) Establishing internal process to receive and respond to CareSource medical record requests via the Provider Portal using submission reason 'Pre Pay Claim Review – Notes Required'; (3) Updating internal documentation checklists for Behavioral Health, Skilled Therapy, DME, POS, Lab & Imaging, and Medical E&M services to ensure all required supporting documents are captured at point of service; (4) Implementing 30-day response protocol to submit requested records before claims are denied; (5) Training providers to document medical decision making, levels of service, modifier usage, service requirements for referrals/orders, and service units per CMS NCCI, AMA CPT, and AHA guidelines. Failure to submit required documentation will result in claim denials that remain in denied status for up to 365 days from claim receipt date. All denial decisions are subject to provider dispute rights per the Provider Manual.