Claim Submission and Prior Approval

Providers should submit claims for services rendered to EMA applicants, on the web portal at mmis.georgia.gov/portal with supporting documentation. Supporting clinical documentation should include form 520 (Provider Inquiry Form), history and physical, any emergency room records, physician’s progress notes, physician order sheets, discharge summary, consultation record, nurse’s notes, and death summary if applicable. Claims without supporting documentation will be denied as incomplete. Providers can follow the procedures for prior approval for clearance as to whether a medical charge or prescription will be covered. However, prior approval does not guarantee payment. Providers who do not routinely submit EMA claims for review and possible payment by Department of Community Health (DCH) should attempt to provide some notice of such policy to the potential EMA member. DCH strongly encourages providers to negotiate payment plans that assist these members with payment of these services. If DCH determines that the EMA claim contains both emergent and non-emergent services, payment will only be rendered for emergency services. Providers will be informed by Gainwell of the need to submit additional documentation to facilitate the rendering of such payment.

Failure to submit the required documentation within 30 days of the date of the split decision notice will result in the denial of the entire claim. If DCH determines that services rendered were non-emergent, providers may bill EMA members for those services. DCH strongly encourages providers to negotiate payment plans that assist these members with payment of these services. Denial of EMA claims are subject to the administrative appeal process as outlined in Part I, Chapter 500. EMA claim denials that result from a provider’s failure to submit these claims according to this subsection are subject to the provisions of Part I, § 106(Q).

For instructions on prior approval providers can refer to Part I Policy and Procedure in the Gainwell Technologies Billing Manual.