Back to dashboard
MedicaidCoverageHigh impact

[Georgia] Avalon Policy Updates - Q3 2024

CareSource·GA·Medical Policy
Effective date
Apr 1, 2025
We identified it
May 9, 2026
Days to comply

Summary

CareSource/Avalon is updating 43 laboratory policies for Georgia Medicaid effective April 1, 2025. These policy revisions affect routine testing management (RTM) and post-service pre-payment clinical claim editing. Billing teams must review each updated policy on Avalon's website and ensure claims comply with new requirements to avoid denials.

Action Required

Action needed
By March 31, 2025: Billing team must access Avalon Healthcare Solutions website and download all 43 updated laboratory policies (F2019, G2002, G2007, G2035, G2036, G2043, G2045, G2048, G2050, G2051, G2059, G2060, G2061, G2063, G2100, G2105, G2107, G2110, G2113, G2115, G2119, G2121, G2123, G2124, G2149, G2150, G2151, G2153, G2154, G2155, G2156, G2157, G2158, G2159, G2173, M2041, M2068, M2097, M2112). Review each policy for changes in coverage criteria, medical necessity requirements, frequency limits, and approved testing scenarios. Update internal billing workflows, EMR templates, and claim submission protocols to reflect new compliance requirements. Providers must document medical necessity per updated policy language. Train billing and coding staff on new requirements. Use CareSource Trial Claim Advice tool on the Provider Portal to test claims before submission. Failure to comply with updated policies will result in claim denials during the RTM pre-payment editing process.