Ga. Medicaid Part II Policies & Procedures for Hospital Services § 802

The attending physician is responsible for obtaining precertification for the services identified in

Section 801 and for providing the precertification number to each Medicaid provider associated with

the case, i.e., assistant physician, hospital, etc. The physician’s failure to obtain the correct

precertification number will be imputed to the hospital and result in denial of payment. If the

attending physician is not currently enrolled as a Medicaid provider or the patient has Medicare Part

B only, the hospital then is responsible for obtaining the precertification number and making it

available to each provider associated with the case.

Requests should be initiated at least one (1) week prior to the planned admission or procedure.

Approval is valid for ninety (90) days from the date of approval. Hospital admissions exceeding ninety

(90) days require recertification within three (3) calendar days prior to the ninetieth (90th) day of the

continued stay. Failure to obtain recertification within the three calendar days of the ninetieth day will

result in denial of the continued stay. No recertification will be granted for any part of the continuous

stay if the request for recertification is received after the ninetieth (90th) day. Precertification and

recertification may be requested by contacting the Gainwell Technology PA/UM online via the web

portal at www.mmis.georgia.gov or by calling Telephone: 1-800-766-4456 (Provider Call Center)

Sections 202.2 of Part 1 addresses timely submission of claims when conditions exist that are beyond

the control of the provider. In accordance with Section 202.2, when an individual is made

retroactively eligible, requests for certification must be received within six (6) months from the month

of determination of retroactive eligibility. Additionally, when members are eligible for both Medicare

and Medicaid, and Medicare benefits are exhausted, requests for certification must be received within

three (3) months of the month of notification of exhaustion of benefits.

In a case in which it is unknown if Medicaid will be the primary payer, you should call the Gainwell

Technology PA/UM Call Center. Medicaid patients with Medicare Part A and B coverage do not

require precertification from Medicaid.

Medicaid patients with Part B only coverage should be precertified. Members with private

insurance and Medicaid should be precertified.

When precertification is not required or has been obtained for an outpatient procedure and during the

procedure, it is determined that additional or a different procedure is necessary (for determining

timeliness or precertification update requests), the additional or different procedure will be

considered an urgent procedure. The hospital’s request for an update of the precertification file will

be considered timely if received within thirty days of the date of the procedure.

When precertification is not required or has been obtained for an outpatient procedure and after the

procedure has been performed, it is determined that inpatient services are necessary (for determining

timeliness of precertification update requests), the admission should be considered an emergency.

The hospital’s request for an update of the precertification file should be considered timely if

received within thirty days of the beginning date of the episode of care.

Requests for updates to the precertification file and retroactive certification of inpatient admissions

following a procedure or service clearly requiring an inpatient level of care that should have been

anticipated will not be considered timely and will be denied.

An outpatient observation status becomes inpatient when the determination is made that inpatient

services are medically necessary (if the length of stay is less than 48 hours) or the length of stay is no

more than 48 hours. In these cases, the request for certification of the inpatient admission must be

received within thirty (30) days of the beginning date of the episode of care (see Section 903.6).