Ga. Medicaid Part II Policies & Procedures for Hospital Services § 604

604.1. Initial Enrollment

In addition to the completion of a Statement of Participation and a Request for Taxpayer

Identification Number and Certification (IRS Form W-9), a hospital also must submit

the following information:

604.1.1. A letter from the state licensing unit showing the bed capacity, permit

number and effective date of the permit.

604.1.2. A document from the state licensing unit showing that the hospital has

been recommended for certification or that it meets the requirements for

the Medicare program. As a Rural Health Hospital

604.1.3. Written evidence that the hospital is in compliance with Title VI, Civil

Rights Act of 1964, as amended.

604.1.4. A copy of the hospital’s current Utilization Review Plan.

604.1.5. When the hospital provides mammography services, a copy of the letter

of certification identifies the mammography certification number.

604.2. Conditions of Enrollment

The general conditions of participation which apply to all providers in the Medicaid

Program are outlined in the Part I. Additionally, the following enrollment conditions

apply to Rural Emergency Hospital providers:

604.2.1. Enrollment as an outpatient hospital services provider only.

604.2.2. Termination of enrollment as an inpatient hospital provider (if currently

enrolled as an inpatient and outpatient hospital provider).

604.2.3. Assigned specialty code 507 – Rural Emergency Hospital.

604.2.4. Provision of care that does not exceed a 24-hour stay (maximum 23

hours and 59 minutes)

604.3. Billing Requirements

When submitting claims, providers must bill revenue code 762 and the applicable

number of hours the members received services, not to exceed a 24-hour stay. Claims

will deny if revenue code 762 is billed in excess of 23 hours and 59 minutes.

(Rev. 10/01/2025)