MedicaidCoverageMedium impact
[Georgia] Avalon Policy Updates - November 2025
CareSource·GA·Medical Policy
Effective date
Jan 1, 2026
We identified it
May 9, 2026
Summary
CareSource/Avalon is updating 20 laboratory testing policies effective January 1, 2026. These policies govern routine testing management (RTM), a post-service pre-payment clinical claim editing program for Georgia Medicaid. Providers must ensure lab orders comply with updated Avalon policies to avoid claim denials during the RTM review process.
Action Required
By December 15, 2025: Billing team must access Avalon's website and review all 20 updated laboratory policies (F2019, G2008, G2022, G2031, G2035, G2042, G2044, G2045, G2099, G2120, G2125, G2138, G2143, G2149, G2164, G2181, M2041, M2057, M2116, M2172, T2015). Document any changes to medical necessity requirements, frequency limits, or covered indications. Before January 1, 2026: Update provider order templates and EMR clinical decision support to reflect new policy requirements. Train clinical and billing staff on changes. Providers should use the Trial Claim Advice Tool on the CareSource Provider Portal to simulate claims for adherence before submission. Failure to comply will result in claim denials during RTM post-service editing.