[Georgia] May 2026 Provider Newsletter

REQUIREMENTS: By June 1, 2026: Billing team must implement correct usage of JW and JZ modifiers for drug waste and full-dose billing on commercial claims. Update billing software and provider education materials. Incorrect modifier usage will result in claim denials or rejections. By July 1, 2026: For Medicare Advantage plans, billing team must ensure all claims for XXX procedures billed with an E&M service include modifier 25. Update billing system logic to require modifier 25 in these scenarios. Update provider encounter forms and templates to remind clinicians. Non-compliant claims will be denied. By August 1, 2026: Billing team and prior authorization staff must implement updated specialty pharmacy criteria and prior authorization requirements. Review Carelon Medical Benefits Management code updates and medical policy changes. Update prior authorization submission workflows and internal reference materials. Contact specialty pharmacy vendors for guidance on new requirements. Prior authorization denials may increase if updated criteria are not properly implemented. By September 1, 2026: Prior authorization team must implement updated precertification/prior authorization requirements for Radiation Oncology and general procedures through Carelon Medical Benefits Management. Update internal authorization protocols and provider communications. By October 1, 2026: Prior authorization team must implement new prior authorization requirements for Musculoskeletal procedures through Carelon Medical Benefits Management. Before June 30, 2026: For hospitals with more than 50 beds: Ensure QHC compliance attestation is submitted by June 30, 2026 to avoid network participation issues. Immediately: Billing team should review all listed policy updates in full detail at the source URL and assign responsibility for each update category (administrative, education & training, policy updates, prior authorization, products & programs, pharmacy).