Ga. Medicaid Part II Policies & Procedures for Hospital Services, Appendix K

A Outpatient Copayment:

A $3 member copayment is required on all non-emergency outpatient hospital visits. Pregnant

women, members under twenty-one (21) years of age, nursing facility members, hospice care

members and woman diagnosed with breast or cervical cancer who is receiving Medicaid under

the Breast and Cervical Cancer (BCC) program or Presumptive Eligibility Aid Categories 245 and

800 only are not subject to the copayment. The copayment does not apply to the following

services: Emergency Services, Family Planning Services, Waiver Services and Dialysis Services.

When the outpatient cost-based settlements are made for hospital services, the copayment plus

Medicaid payment will be compared to the allowable cost to determine the amount of final

settlement.

B. Inpatient Copayment:

A copayment of $12.50 will be imposed on hospital inpatient services.

Members affected by the co-payment are limited to adult members of Supplemental Social

Security Income (SSI) benefits, certain other adult disabled and aged members and parents of

children receiving Aid to Families with Dependent Children (AFDC) benefits. Children under age

twenty-one (21), pregnant women, nursing facility residents, or hospice care members and

members receiving family planning services are not required to pay this co-payment. Emergency

services received by Medicaid members do not require a co-payment. Services cannot be denied

based on the inability to pay these co-payments

Women diagnosed with breast or cervical cancer and receiving Medicaid under the Women’s

Health Medicaid Program (aid category 245 and 800 only) are exempt from co-pay.

Inpatient services must have the Type of Admission, Form Locator 19, and Source of Admission,

Form Locator 20, completed on the UB-04 claim form. Type of Admission one (1) Emergency

and two (2) Urgent are exempt from inpatient co-payment.

Source of Admission codes 4, 5, and 6 are exempt from inpatient co-payment.

4 = Transfer from a Hospital

5 = Transfer from a Skilled Nursing Home

6 = Transfer from another Health Facility

The provider should check the member’s eligibility via web or telephone each month in order to

identify those individuals who may be responsible for the co-payment.

Gainwell Technology will automatically deduct the copayment amount from the provider’s

payment for claims processed. Do not deduct the copayment from your submitted charges. The

application of the copayment will be identified on the remittance advice. An explanation of

benefit (EOB) code will indicate payment has been reduced due to the application of copayment.

C. COMPLETION OF THE MEDICAID PRECERTIFICATION FORM

The DMA guidelines, set forth in Part II, Chapter 800 of the Policies and Procedure for Hospital

Services manual discuss precertification program requirements and procedures. Request for

Medicaid precertification should be initiated at least one (1) week prior to the planned admission

or procedure. Precertification may be requested by contacting GMCF by any one of the following

two methods: (1) telephone: Telephone: 1-800-766-4456 (Provider Call Center) or (2) web portal.