CareSource | Provider Manual CareSource Georgia Medicaid Provider Manual Georgia Families® (Medicaid/PeachCare for Kids®) Planning for Healthy Babies® PB CareSource.com CareSource.com I CareSource | Provider Manual This content has been reviewed; however, changes and/or revisions occur frequently. Providers should check our website at CareSource.com for the most current version of this manual. II CareSource.com CareSource.com III CareSource | Provider Manual Dear CareSource® provider, Welcome to CareSource, and thank you for your participation. CareSource values you as a health partner, and we are actively working to make it easier for you to deliver quality care to our members. The CareSource Provider Manual is intended as a resource for working with our plan. It communicates policies and information about our programs. This manual also outlines key information, such as claim submission and reimbursement processes, authorizations, member benefits and more to make it easier for you to do business with us. This manual is available on CareSource.com > Providers > Tools & Resources > Provider Manual, selecting Georgia Medicaid from the dropdown menu, or you may request a hard copy by calling Provider Services at 1-855-202-1058. CareSource communicates updates with our network regularly through network notifications available on the Updates & Announcements page on CareSource.com > Providers > Tools & Resources > Updates & Announcements, selecting Georgia Medicaid from the dropdown menu, and on our secure Provider Portal at CareSource.com > Login > Provider, selecting Georgia from the menu. In an effort to better support our providers and offer an immediate response to questions, concerns and inquiries, we offer claim, policy and appeal assistance through our call center at 1-855-202-1058. If you have questions or concerns, you may ask to speak to a member of our Provider Relations team by calling our toll-free number. We know great health care begins with you. Together we can help attain better outcomes for our CareSource members. Sincerely, II CareSource.com CareSource.com III CareSource | Provider Manual TABLE OF CONTENTS About CareSource ........................................................................................................................................1 Welcome ......................................................................................................................................................1 Vision & Mission ..........................................................................................................................................2 Our Services ................................................................................................................................................2 The CareSource Foundation ........................................................................................................................3 Corporate Compliance .................................................................................................................................3 Accreditation ................................................................................................................................................4 Georgia Families Program Description ........................................................................................................4 PeachCare for Kids® Program Description ...................................................................................................5 Planning for Healthy Babies® Program Description ......................................................................................5 Georgia Families® Service Areas .................................................................................................................5 Communicating with CareSource ...............................................................................................................6 Hours of Operation ......................................................................................................................................6 Phone ..........................................................................................................................................................7 Website ........................................................................................................................................................7 CareSource Provider Portal .........................................................................................................................8 Benefits .....................................................................................................................................................8 Registration ...............................................................................................................................................9 GAMMIS Portal ............................................................................................................................................9 Demographic Changes ................................................................................................................................9 Office of the Ombudsman ............................................................................................................................9 Mail ............................................................................................................................................................10 Fax .............................................................................................................................................................11 Newsletters ................................................................................................................................................11 Network Notifications .................................................................................................................................11 Member Enrollment, Eligibility & Payment Responsibility .....................................................................12 Medicaid Enrollment ..................................................................................................................................12 Newborn Enrollment ..................................................................................................................................12 Disenrollment .............................................................................................................................................13 Georgia Families® Eligibility .......................................................................................................................14 PeachCare for Kids® Eligibility ...................................................................................................................15 Planning for Healthy Babies® Eligibility ......................................................................................................15 New Member ID Cards and Kits .................................................................................................................16 Verify Eligibility ...........................................................................................................................................16 Payment Responsibility ..............................................................................................................................17 Member Support Services & Benefits ......................................................................................................19 Member Services .......................................................................................................................................19 CareSource24®, Nurse Advice Line ...........................................................................................................19 Disease Management ................................................................................................................................20 Care Management .....................................................................................................................................21 Health Education........................................................................................................................................24 Reward and Incentives Programs ..............................................................................................................24 Interpreter Services ....................................................................................................................................28 Covered Services ...................................................................................................................................... 29 Medicaid and PeachCare for Kids® ........................................................................................................... 30 IV CareSource.com CareSource.com V CareSource | Provider Manual Benefit Limits ............................................................................................................................................ 34 Planning for Healthy Babies® .................................................................................................................... 34 Prior Authorization .....................................................................................................................................39 Medical Necessity Standards & Practice Guidelines .................................................................................39