MedicaidCoverageMedium impact
[Georgia] Avalon Policy Updates - Q4 2024
CareSource·GA · Family Medicine, Internal Medicine, Pediatrics +5 more·Medical Policy
Effective date
Sep 1, 2025
We identified it
May 9, 2026
Summary
CareSource has updated 14 laboratory testing policies through its Avalon Healthcare Solutions partnership, effective September 1, 2025. These policy changes affect routine testing management (RTM) and post-service pre-payment clinical claim editing for Georgia Medicaid members. The billing team must review each updated policy on Avalon's website and use the Trial Claim Advice tool to validate laboratory claims for compliance before submission.
Action Required
By August 25, 2025: Billing team must review all 14 updated Avalon laboratory policies (G2005, G2006, G2011, G2013, G2014, G2056, G2098, G2149, G2154, G2174, M2067, M2141, M2176, P2018, R2162) on Avalon's website and document any changes to testing requirements, medical necessity criteria, or billing restrictions. Before September 1, 2025: Providers must begin using the Trial Claim Advice tool on the CareSource provider portal to simulate all laboratory claims containing routine testing services to ensure compliance with updated policies. Update laboratory order guidelines and internal billing workflows to reflect new RTM program requirements. Failure to comply with these policies may result in claim denials during post-service pre-payment editing.