Georgia Medicaid Managed Care Quality (2026): HEDIS, CAHPS, EQRO, Withholds, Appeals

::hero{eyebrow="Georgia Medicaid" headline="Georgia Medicaid Managed Care Quality" subhead="How 42 CFR Part 438 federal managed care regulation establishes the quality framework, how HEDIS clinical quality measures and CAHPS member experience surveys quantify CMO performance, how the annual EQRO Technical Report independently validates plan performance, how quality withholds and performance improvement projects create accountability, how grievance and appeal rights including aid paid pending and the State Fair Hearing protect members, how the 2024 CMS Managed Care Access Final Rule strengthened appointment wait time and network adequacy standards, and how Georgia families use quality data to choose a plan, file a grievance, appeal a denial, and hold their CMO accountable."} ::

Most Georgia Medicaid beneficiaries receive their coverage through a Care Management Organization, the term Georgia uses for what other states call a Medicaid Managed Care Organization or MCO. The four Georgia CMOs are Amerigroup Community Care of Georgia, CareSource Georgia, Peach State Health Plan, and Wellpoint Georgia. The Georgia Department of Community Health contracts with these four organizations to deliver Medicaid benefits, manage networks, authorize services, pay providers, and coordinate care for the majority of Georgia Medicaid beneficiaries. The state pays each CMO a capitated monthly payment per enrolled member. The CMO is responsible for delivering the benefit package within that capitation, and the CMO bears the financial risk if costs exceed the capitated amount.

This arrangement creates an obvious tension. A CMO has a financial incentive to limit utilization, which can manifest as service denials, narrow networks, slow appeals, and underinvestment in preventive care. To counteract these incentives, federal Medicaid law and Georgia state law establish an elaborate quality framework. Federal regulations at 42 CFR Part 438 require each CMO to maintain a Quality Assessment and Performance Improvement program, undergo annual independent External Quality Review, meet network adequacy and access standards, and operate a grievance and appeal system that includes aid paid pending and the right to a State Fair Hearing. The state of Georgia adds quality withholds tied to performance measures, Performance Improvement Projects on priority topics, annual member experience surveys, secret shopper network validation, and operational monitoring across multiple dimensions.

For Georgia families, this framework is more than regulatory abstraction. It is the mechanism through which a parent gets a delayed mental health appointment scheduled within ten business days, through which a pregnant woman with a denied ultrasound gets that denial overturned on appeal, through which a member transferring between CMOs can compare apples-to-apples quality data, and through which a CMO that fails to deliver loses real money. This guide translates the framework. It covers the federal authorities, the Georgia implementation, the major HEDIS clinical quality measures, the CAHPS member experience survey, the EQRO Annual Technical Report, NCQA Health Plan Accreditation, the quality withhold structure, the grievance and appeal process step by step, network adequacy standards including the 2024 CMS Final Rule's enforceable appointment wait time standards, sanctions and enforcement, and how members can use all of this to make informed choices and hold their CMO accountable. Six worked examples illustrate how the framework operates for real Georgia families. A frequently asked questions section addresses the most common questions members ask. A contact directory provides the phone numbers needed to file a grievance, request a fair hearing, switch plans, or escalate a complaint.

::callout{title="Key takeaways"}

• Most Georgia Medicaid beneficiaries are enrolled in one of four Medicaid CMOs: Amerigroup Community Care, CareSource Georgia, Peach State Health Plan, or Wellpoint Georgia. Each operates under a multi-year contract with the Georgia Department of Community Health.
• The federal managed care regulation at 42 CFR Part 438 establishes the quality framework. It requires each CMO to maintain a Quality Assessment and Performance Improvement program, undergo annual External Quality Review by an independent organization, meet network adequacy and access standards, and operate a compliant grievance and appeal system.
• HEDIS (Healthcare Effectiveness Data and Information Set) measures from NCQA quantify clinical quality across dozens of topics including well-child visits, prenatal and postpartum care, diabetes care, blood pressure control, behavioral health follow-up, cancer screening, immunizations, and asthma management. CMO HEDIS scores are public and comparable across the four Georgia CMOs.
• CAHPS (Consumer Assessment of Healthcare Providers and Systems) member experience surveys measure how members rate their personal doctor, their plan, customer service, getting needed care, and getting care quickly. CAHPS scores are also public and comparable.
• The EQRO Annual Technical Report is an independent assessment of each CMO produced annually by a vendor under contract to DCH. It validates HEDIS measures, validates Performance Improvement Projects, assesses information systems, evaluates network adequacy, and identifies areas for improvement. The report is publicly available on the DCH website.
• All four Georgia CMOs are typically accredited by the National Committee for Quality Assurance (NCQA), an additional voluntary plan-level quality certification.
• Georgia DCH withholds a portion of each CMO's capitation payment (typically 1 to 5 percent) that the CMO can earn back by meeting performance targets. Quality withholds create real financial incentive for performance, with potential withhold dollars on a single contract reaching tens of millions per year.
• Members can switch CMOs within 90 calendar days of initial enrollment for any reason, during the annual open enrollment period, and at any time for cause (such as a service quality issue or network gap).
• A grievance covers any expression of dissatisfaction other than an adverse benefit determination. An appeal covers denials, reductions, or terminations of services. Members file appeals first with their CMO, then can request a State Fair Hearing before an Administrative Law Judge if dissatisfied.
• Aid paid pending allows continuation of services during appeal if the appeal is filed promptly after notice. Expedited appeals are resolved quickly when standard timeframes could jeopardize health.
• The 2024 CMS Medicaid Managed Care Access Final Rule (CMS-2439-F) introduced enforceable appointment wait time standards for primary care, OB/GYN, and outpatient mental health and substance use disorder services, validated by annual secret shopper surveys.
• Network adequacy standards apply to behavioral health on a parity basis with medical/surgical services under the Mental Health Parity and Addiction Equity Act of 2008.
• Sanctions for CMO noncompliance can include liquidated damages, civil money penalties, enrollment freezes, suspension of capitation payments, mandatory corrective action plans, and ultimately contract termination. ::

The federal framework

By Brevy Care Team · Last verified May 12, 2026

Section 1932 and the Balanced Budget Act of 1997

Section 1932 of the Social Security Act, codified at 42 USC 1396u-2, provides the statutory authority for state Medicaid programs to require enrollment in managed care. Before the Balanced Budget Act of 1997, states needed a Section 1115 demonstration waiver or a Section 1915(b) waiver to operate mandatory Medicaid managed care. The Balanced Budget Act of 1997 created Section 1932 and made managed care a state plan option, vastly simplifying state expansion of managed care. Section 1932 also established federal protections including choice of plans, grievance and appeal rights, marketing rules, and quality measurement.

The Benefits Improvement and Protection Act of 2000 enhanced grievance and appeal rights and the External Quality Review requirements. The Affordable Care Act of 2010 expanded managed care provisions including marketplace coordination and quality reporting. The Mental Health Parity and Addiction Equity Act of 2008 applied to Medicaid managed care beginning in 2016 and requires behavioral health benefits to be no more restrictive than medical/surgical benefits in scope, frequency, duration, and network access. The 21st Century Cures Act of 2016 added encounter data reporting requirements and various beneficiary protections. The Consolidated Appropriations Act of 2023 included provisions affecting postpartum Medicaid coverage and children's eligibility, implemented in Georgia managed care.

42 CFR Part 438: The cornerstone regulation

The Centers for Medicare and Medicaid Services implemented Section 1932 and related authorities through 42 CFR Part 438, the comprehensive federal regulation governing Medicaid managed care. Part 438 contains nine subparts addressing state responsibilities, beneficiary protections, quality, External Quality Review, grievance and appeal systems, network adequacy, program integrity, sanctions, and rate setting. Several subparts are particularly important for the quality framework.

42 CFR 438.330 requires each CMO to operate a Quality Assessment and Performance Improvement program. The QAPI program must include Performance Improvement Projects in clinical and nonclinical areas, performance measurement and reporting (including HEDIS measures), mechanisms to detect both underutilization and overutilization, and special mechanisms to assess quality for members with special health care needs.

42 CFR 438.350 through 438.370 govern External Quality Review. States must contract with one or more External Quality Review Organizations (EQROs) to conduct annual mandatory EQR activities. The mandatory activities under 42 CFR 438.358 include compliance review against Part 438 standards, validation of CMO-reported performance measures (HEDIS), and validation of Performance Improvement Projects. The EQRO produces an Annual Technical Report under 42 CFR 438.364 that synthesizes findings across all CMOs in the state. The Annual Technical Report is a public document, posted on the state Medicaid agency website.

42 CFR 438.402 through 438.424 establish the grievance and appeal system. The CMO must maintain a written grievance and appeal process, accept oral and written filings, resolve standard appeals within required timeframes and expedited appeals promptly, allow members to appoint a representative, provide free interpretation services, and notify members of the right to a State Fair Hearing.

42 CFR 438.206 and 438.207 establish network adequacy and access standards. The state must ensure that CMOs maintain provider networks sufficient to meet the needs of enrollees, with time and distance standards, appointment wait time standards, and specialty access requirements.

42 CFR 438.6 covers special contract provisions related to payment, including pass-through payments, state-directed payments, quality withholds, and performance incentive arrangements. This is the regulatory basis for the quality withhold structure that Georgia uses.

CMS-2390-F: The 2016 Final Rule

In May 2016, CMS issued the Medicaid Managed Care Final Rule, designated CMS-2390-F. The 2016 Final Rule was the first comprehensive update to Part 438 since 2002. It aligned managed care more closely with Medicare Advantage and commercial managed care standards in several areas:

• Required Medical Loss Ratio (MLR) reporting, ensuring a minimum share of capitation goes to medical care rather than administration and profit
• Modernized network adequacy with time-and-distance standards by service type and geography type
• Required Quality Rating Systems to allow consumer comparison
• Required Beneficiary Support Systems including choice counseling
• Strengthened quality strategy requirements
• Updated information requirements at 42 CFR 438.10 including provider directories, member handbooks, and enrollee notifications

The 2016 Final Rule's provisions were phased in over several years and form the operational baseline for current managed care.

CMS-2439-F: The 2024 Access Final Rule

In May 2024, CMS issued a major update titled the Medicaid Managed Care Access, Finance, and Quality Final Rule, designated CMS-2439-F. The 2024 Access Final Rule focused on strengthening enforceable access standards and quality transparency:

• Appointment wait time standards: New enforceable appointment wait time standards require timely access to routine primary care, OB/GYN, and outpatient mental health and substance use disorder services within specified business-day windows.
• Annual secret shopper surveys: States must conduct annual secret shopper surveys of CMO provider directories to validate provider availability, appointment wait times, and directory accuracy.
• State directed payment transparency: Enhanced reporting on state directed payments and pass-through payments.
• Quality rating system standardization: Standardized public reporting of plan quality ratings across states.
• Strengthened grievance and appeal reporting: Public reporting of grievance and appeal volumes, dispositions, and overturn rates.
• Enhanced ombudsman requirements: Strengthened Beneficiary Support System and member advocacy.

The 2024 Final Rule's provisions phase in through 2026 and 2027. Georgia DCH and the four CMOs are implementing the new requirements on the federal timeline.

Quality measurement: HEDIS, CAHPS, and NCQA

Two non-governmental organizations supply the core quality measurement instruments used in Medicaid managed care.

The National Committee for Quality Assurance, a nonprofit accreditation and measurement organization, publishes the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS is a standardized set of clinical quality measures with detailed technical specifications for denominators, numerators, exclusions, and data sources. The HEDIS measure set is updated annually with measure additions, retirements, and methodological refinements. Health plans report HEDIS measures using either administrative data, hybrid sampling, or electronic clinical data. CMO HEDIS results are audited by HEDIS Compliance Auditors before submission. NCQA also offers voluntary Health Plan Accreditation, a comprehensive plan-level certification covering quality management, utilization management, credentialing, member experience, member rights, and population health management.

The Agency for Healthcare Research and Quality, a federal agency, develops the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey instruments. The Adult CAHPS Medicaid 5.1H and the Child CAHPS Medicaid (with chronic conditions supplement) are standardized member experience surveys covering composite domains (getting needed care, getting care quickly, how well doctors communicate, customer service) and global ratings (personal doctor, specialist, all health care, health plan). CAHPS surveys are administered annually or biennially by independent survey vendors.

HEDIS measures clinical quality. CAHPS measures member experience. NCQA accreditation certifies plan-level capability. Together, HEDIS, CAHPS, and NCQA accreditation form the backbone of Medicaid managed care quality measurement.

The Georgia framework

Georgia Families and the four CMOs

The Georgia Families program is the state's mandatory Medicaid managed care program for most Medicaid beneficiaries. The program is administered by the Georgia Department of Community Health under contracts with four Care Management Organizations.

Amerigroup Community Care of Georgia is a subsidiary of Elevance Health (formerly Anthem). Amerigroup has been a Georgia CMO since the Georgia Families program launch. Member services 1-800-600-4441. Amerigroup also operates the Georgia Families 360 degrees specialized program for children in foster care and former foster care youth.

CareSource Georgia is the Georgia operation of CareSource, a member-focused not-for-profit headquartered in Dayton Ohio. Member services 1-855-202-0729.

Peach State Health Plan is a subsidiary of Centene Corporation. Peach State has been a Georgia CMO since the Georgia Families program launch. Member services 1-800-704-1484.

Wellpoint Georgia is the rebranded former Anthem Georgia, now operating under the Wellpoint name. Wellpoint Georgia is also a subsidiary of Elevance Health. Member services 1-800-300-8181. Wellpoint operates as a separate CMO from Amerigroup with separate contracts, networks, and operations, despite both being Elevance Health subsidiaries.

Georgia Families covers most Medicaid beneficiaries including children, parents, pregnant women, Pathways to Coverage adults, and ABD (Aged, Blind, and Disabled) beneficiaries. Excluded populations include nursing facility residents, PACE participants, and certain other carve-out categories.

The Georgia Families 360 degrees program is a specialized managed care arrangement for children in foster care, children in adoption assistance, and former foster care youth up to age 26. The Georgia Families 360 degrees contract is operated by Amerigroup statewide and includes enhanced care coordination, trauma-informed care, and behavioral health integration.

The Planning for Healthy Babies (P4HB) Section 1115 demonstration provides family planning and interpregnancy care services to women within a specified income range. P4HB is CMO-administered.

The Pathways to Coverage Section 1115 demonstration covers adults within an income range who meet work or educational engagement requirements. Pathways enrollees receive coverage through the four Georgia Families CMOs.

The DCH quality framework

Georgia DCH operationalizes the federal quality framework through a multi-component structure.

The Georgia Quality Strategy, required by 42 CFR 438.340, is the state-level strategic document covering quality goals, priority performance measures, the External Quality Review strategy, beneficiary protections, and quality assessment activities. The Georgia Quality Strategy is updated periodically and posted publicly on the DCH website.

The DCH-CMO contracts are the operational backbone. Each CMO operates under a multi-year contract that specifies quality requirements, performance metrics, network standards, encounter data requirements, grievance and appeal procedures, and the quality withhold structure. Contracts run on a multi-year cycle with renewal options.

The DCH Office of Quality and Health Policy is the lead office for managed care quality oversight. The office tracks CMO performance, manages the EQRO contract, oversees Performance Improvement Projects, administers quality withhold calculations, and reports to DCH leadership and the CMS Regional Office.

The DCH-EQRO contract funds External Quality Review activities. The EQRO is procured competitively. The EQRO conducts the annual technical assessment of each CMO, validates HEDIS measures, validates Performance Improvement Projects, administers and reports CAHPS surveys, assesses information systems, reviews network adequacy, validates encounter data, and produces the Annual Technical Report.

The DCH-DPH-DBHDD interagency agreements coordinate across the Department of Community Health, the Department of Public Health (which administers EPSDT outreach, immunization registries, maternal and child health, and vital statistics), and the Department of Behavioral Health and Developmental Disabilities (which administers the public behavioral health system). The interagency structure ensures that managed care quality activities align with broader Georgia public health and behavioral health goals.

HEDIS measures used by Georgia DCH

Georgia DCH and the four CMOs report on a wide range of HEDIS measures annually. The most prominent measures fall into several categories.

Well-child visits and pediatric care

The W-30 measure (Well-Child Visits in the First 30 Months of Life) has two indicators: a 0-15 months indicator requiring six or more well-child visits and a 15-30 months indicator requiring two or more visits. The WCV measure (Child and Adolescent Well-Care Visits) covers ages 3 through 21. The CIS measure (Childhood Immunization Status) tracks completion of the recommended childhood immunization schedule through age 2, with multiple combination indicators. The IMA measure (Immunizations for Adolescents) tracks adolescent immunizations including meningococcal, Tdap, and HPV. The HPV measure tracks the HPV vaccine series specifically for adolescents.

Maternal and reproductive health

The PPC measure (Prenatal and Postpartum Care) has two indicators: timeliness of prenatal care (first prenatal visit in the first trimester or shortly after enrollment) and postpartum care (a visit within an appropriate window after delivery). PPC is one of the most important Georgia HEDIS measures given the state's high rate of maternal mortality and morbidity. The LSC measure (Live-Born Singleton Cesarean Birth) tracks the rate of cesarean section among low-risk first-time deliveries. The CHL measure (Chlamydia Screening in Women) covers ages 16-24. The CCS measure (Cervical Cancer Screening) and the BCS measure (Breast Cancer Screening) cover adult women.

Chronic disease management

The CDC measure (Comprehensive Diabetes Care) is a composite of multiple indicators including HbA1c testing, HbA1c control below 8 percent, eye exam, blood pressure control, and medical attention for nephropathy. The GSD measure (Glycemic Status Assessment for Patients with Diabetes) reflects the newer HEDIS framing of glycemic control. The CBP measure (Controlling High Blood Pressure) tracks blood pressure control within normal thresholds for adults. The ASM and AMR measures cover asthma medication management. The PCR measure (Plan All-Cause Readmissions) tracks 30-day acute hospital readmissions.

Behavioral health

The AMM measure (Antidepressant Medication Management) tracks both the acute phase and the continuation phase of continuous antidepressant treatment. The FUH measure (Follow-Up After Hospitalization for Mental Illness) tracks 7-day and 30-day post-discharge follow-up. The FUM and FUA measures track follow-up after emergency department visits for mental health and for alcohol or other drug abuse. The IET measure (Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment) tracks substance use treatment engagement. The SSD measure (Diabetes Screening for People with Schizophrenia or Bipolar Disorder Using Antipsychotic Medications) addresses cardiometabolic monitoring in the seriously mentally ill population.

HIV and adult preventive

The HVL measure (HIV Viral Load Suppression) tracks viral load suppression in people living with HIV. The AAP measure (Adults' Access to Preventive/Ambulatory Health Services) tracks adult access to a primary care visit. The COL measure (Colorectal Cancer Screening) tracks colorectal screening completion.

Each year the EQRO Annual Technical Report publishes each CMO's score on each measure and the percentile rank against national Medicaid plan benchmarks. The data is comparable across the four Georgia CMOs.

CAHPS member experience in Georgia

Georgia DCH administers Adult CAHPS Medicaid and Child CAHPS Medicaid surveys annually or biennially. Survey results inform both DCH quality monitoring and the EQRO Annual Technical Report.

Composite scores include Getting Needed Care, Getting Care Quickly, How Well Doctors Communicate, and Customer Service. Global rating scores include Rating of Personal Doctor, Rating of Specialist Seen Most Often, Rating of All Health Care, and Rating of Health Plan. The Coordination of Care composite addresses care management and provider communication.

CAHPS scores are published in the EQRO Annual Technical Report and on the DCH website, allowing members to compare member experience across the four CMOs.

Quality withholds and performance incentives

Under 42 CFR 438.6, Georgia DCH withholds a portion of each CMO's monthly capitation payment. The withheld dollars are released to the CMO when the CMO meets specified performance targets. The withhold percentage and the target measures are specified in each contract year. Typical withhold structures apply a percentage of total capitation to specified measures with weighted targets.

Examples of common withhold-tied measures:

• HEDIS PPC timeliness of prenatal care
• HEDIS PPC postpartum care
• HEDIS W-30 well-child visits in the first 30 months
• HEDIS FUH 7-day follow-up after psychiatric hospitalization
• HEDIS CDC diabetes control
• HEDIS CBP blood pressure control
• CAHPS Rating of Health Plan
• Network adequacy compliance
• Grievance and appeal resolution timeliness
• Encounter data quality

The withhold structure creates real financial accountability. The dollar magnitude is large enough to drive CMO management attention and operational resources toward quality improvement.

Performance Improvement Projects

Under 42 CFR 438.330(d), each CMO must conduct ongoing Performance Improvement Projects. PIPs are structured improvement initiatives addressing a measurable quality indicator using sound methodology with continuous data collection and sustained improvement targets.

Typical Georgia CMO PIP topics include increasing well-child visit completion, increasing prenatal care timeliness in the first trimester, increasing postpartum visit attendance, reducing asthma-related emergency department visits, improving 7-day and 30-day follow-up after psychiatric hospitalization, increasing diabetes HbA1c control, increasing immunization rates, and reducing 30-day all-cause readmissions.

PIPs follow rapid-cycle improvement methodology with Plan-Do-Study-Act cycles, run charts, and statistical process control. The EQRO validates each CMO's PIPs annually, scoring them on methodology and outcomes.

NCQA Health Plan Accreditation in Georgia

All four Georgia CMOs are typically NCQA-accredited, although accreditation cycles and statuses can shift over time. NCQA accreditation is voluntary at the federal level but typically required by the DCH-CMO contract or de facto expected by DCH.

NCQA Health Plan Accreditation evaluates plans against detailed standards across quality management and improvement, utilization management (including timeliness, denials, and appeals), credentialing and recredentialing, members' rights and responsibilities, member experience, and population health management. NCQA conducts site visits, reviews documentation, and audits files. Accreditation runs on a multi-year cycle, with periodic surveillance reviews and interim corrective actions for identified deficiencies.

NCQA accreditation status is public on the NCQA website. The four Georgia CMOs' accreditation status can be looked up by anyone, including prospective enrollees making plan choice decisions.

Choosing and switching CMOs

When members can choose or switch

A new Medicaid beneficiary in Georgia Families can choose any of the four CMOs at enrollment. If the member does not choose, DCH auto-assigns the member based on algorithms that consider prior plan enrollment, family member enrollment, geographic factors, and CMO performance.

After initial enrollment, members can switch CMOs:

• Within 90 calendar days of initial enrollment for any reason. No cause required.
• During the annual open enrollment period. DCH conducts annual open enrollment, typically in the fall, during which any enrollee can switch CMOs for any reason.
• For cause at any time. Cause includes service quality issues (significant unresolved access or quality problems), provider network gaps (the member's needed providers are not in network), geographic moves (the member moves outside the CMO's service area, although all four Georgia CMOs serve statewide), religious or cultural reasons, and other approved reasons. The member files a request with DCH or Georgia Families Enrollment, which evaluates the cause.

How to compare CMOs

Members can use multiple data sources to compare the four CMOs:

• DCH Member Handbook materials posted on the Georgia Families website
• The EQRO Annual Technical Report, which presents HEDIS and CAHPS scores by CMO with national benchmarks
• NCQA Accreditation status and ratings for each CMO at ncqa.org
• Provider directories (does my doctor accept this CMO? does this CMO have my specialty?)
• Plan-specific benefits beyond the minimum, sometimes including enhanced transportation, gym memberships, over-the-counter benefits, telehealth platforms, and care coordination programs
• Word of mouth from family and community

Georgia Families Enrollment at 1-888-423-6765 provides choice counseling to members trying to decide.

Grievance, appeal, and State Fair Hearing rights

Grievance vs. appeal

Under 42 CFR 438.400, a grievance is an expression of dissatisfaction about any matter other than an adverse benefit determination. Examples: rude staff, long wait at the clinic, problems with the provider directory, dissatisfaction with the quality of care, network issues, billing problems, transportation problems, and customer service issues. There is no formal Notice of Adverse Benefit Determination triggering a grievance. The member files a grievance to make the CMO aware of a problem and request a response.

An appeal is a request for review of an adverse benefit determination. An adverse benefit determination is defined in 42 CFR 438.400 and includes: a denial or limited authorization of a requested service, including the type or level of service; a reduction, suspension, or termination of a previously authorized service; a denial in whole or in part of payment for a service; a failure to provide services in a timely manner; a failure of the CMO to act within the required timeframes for resolution of grievances or appeals; or for residents of rural areas with only one CMO, a denial of the enrollee's request to obtain services outside the network.

The Notice of Adverse Benefit Determination

Under 42 CFR 438.404, when a CMO makes an adverse benefit determination, the CMO must send the member a written Notice of Adverse Benefit Determination. The notice must include:

• A clear statement of the adverse action being taken
• A clear statement of the reason for the action, with reference to the specific regulations, contract provisions, or clinical guidelines supporting the action
• A statement of the member's right to file an appeal and the applicable timeframe for filing
• A statement of the member's right to request a State Fair Hearing after exhausting the CMO appeal
• A statement of the right to aid paid pending (continuation of benefits) and how to request it
• A statement of the right to request expedited resolution and the criteria for expedited review
• A statement of available assistance including free interpretation services and the right to appoint a representative
• The CMO's contact information for filing

Filing an internal CMO appeal

The member files the appeal with the CMO within the required timeframe after the Notice of Adverse Benefit Determination. The appeal can be filed orally or in writing. If filed orally, the member must follow up in writing unless the appeal is expedited. The member can appoint a representative including a family member, advocate, or attorney to act on the member's behalf.

The CMO must acknowledge the appeal in writing promptly. The CMO must resolve the standard appeal within required timeframes. The CMO may request a limited extension if the member requests it or if additional information is needed.

The appeal must be reviewed by a person or persons not involved in the original adverse benefit determination. For medical necessity decisions, the appeal must be reviewed by a clinical peer (a physician or other clinical professional with appropriate expertise).

If the CMO upholds the adverse benefit determination, the CMO sends the member a Notice of Appeal Resolution explaining the decision and the member's right to request a State Fair Hearing.

Expedited appeals

If the standard 30-day timeframe could seriously jeopardize the member's life, physical or mental health, or ability to attain, maintain, or regain maximum function, the member can request an expedited appeal. The CMO must resolve expedited appeals within an expedited timeframe. Expedited appeals are typically appropriate for denials of urgent medical or behavioral health services, denials of medications needed for ongoing treatment, or terminations of ongoing services where interruption would cause acute harm.

The member can request expedited review at the time of filing. If the CMO denies the expedited request and converts to standard review, the CMO must notify the member promptly and the member can challenge the conversion.

Aid paid pending (continuation of benefits)

Under 42 CFR 438.420, if the appeal involves a termination, suspension, or reduction of a previously authorized service, and the member files the appeal promptly after receiving notice, and the member specifically requests continuation of benefits, the CMO must continue the services through the appeal resolution.

Aid paid pending is a critical due process protection ensuring that termination of a previously authorized benefit cannot occur without an opportunity for review. Members exercising aid paid pending continue receiving the service during the appeal. If the appeal upholds the CMO's adverse action, the member may technically be liable for the cost of services received during continuation, although in practice this liability is rarely enforced for routine Medicaid services.

Aid paid pending also extends to a State Fair Hearing if requested within the State Fair Hearing filing window.

Requesting a State Fair Hearing

After the CMO appeal is resolved (or after the required resolution period has passed without resolution), the member can request a State Fair Hearing.

The State Fair Hearing is a formal administrative proceeding before an Administrative Law Judge of the Georgia Office of State Administrative Hearings (OSAH). The hearing is the member's opportunity to challenge the CMO's adverse benefit determination before an independent decision-maker.

To request a State Fair Hearing, the member files a written request with DCH or OSAH within the applicable filing window after the CMO's Notice of Appeal Resolution. The hearing typically occurs by phone or video, although the member can request an in-person hearing. The member can attend with a representative, bring witnesses, present evidence, and cross-examine the CMO's witnesses. The CMO and DCH may participate as parties.

The ALJ issues a written decision applying federal and state Medicaid law to the facts of the case. The decision is then issued as a final agency action by DCH. The member can seek further review in superior court if dissatisfied.

The State Fair Hearing process typically takes 60 to 120 days from filing to final decision. Aid paid pending continues throughout if requested.

How often appeals are overturned

The EQRO Annual Technical Report publishes appeal overturn rates by CMO. Overturn rates vary across CMOs and across categories of denials. Behavioral health and pharmacy denials are commonly overturned at higher rates than medical/surgical service denials. The overturn data informs DCH oversight and CMO improvement work.

A high overturn rate suggests that the CMO is denying services that ultimately do not survive review, which can indicate inappropriate utilization management practices. DCH uses appeal data as one input to identify CMOs requiring additional oversight or corrective action.

Network adequacy and access standards

Federal standards

42 CFR 438.206 requires the state to ensure that CMOs maintain provider networks sufficient to provide adequate access to all services covered under the contract. 42 CFR 438.207 requires the state to develop and enforce specific access standards. Standards must address:

• Time and distance to network providers (by service type, geography type)
• Provider-to-enrollee ratios for certain service types
• Appointment wait times for routine, urgent, and emergent care
• Specialty access including pediatric subspecialty access
• Geographic distribution of providers
• Cultural and linguistic capabilities of the network
• Accessibility for members with disabilities

CMS-2439-F 2024 wait time standards

The 2024 CMS Medicaid Managed Care Access Final Rule introduced enforceable nationwide minimum appointment wait time standards for routine primary care, routine OB/GYN, and outpatient mental health and substance use disorder services. These are minimum federal standards. States can adopt tighter standards. Annual secret shopper surveys by an independent vendor validate that the standards are being met. The standards are enforceable, meaning DCH can impose corrective action plans, liquidated damages, or other sanctions on CMOs that fail to meet them.

Georgia application

DCH-CMO contracts specify time-and-distance standards by service category and county type. Urban counties such as Fulton, DeKalb, Cobb, Gwinnett, and Chatham have tighter standards. Rural counties such as Lincoln, Glascock, Quitman, Wheeler, and Clay have looser standards reflecting provider scarcity, but with required CMO efforts to expand access via telehealth, out-of-network arrangements, and provider recruitment incentives.

Behavioral health parity

The Mental Health Parity and Addiction Equity Act of 2008 requires that behavioral health network adequacy be no more restrictive than medical/surgical network adequacy. CMOs must demonstrate parity in network composition, appointment access, prior authorization requirements, and out-of-network access. CMS and DCH scrutinize parity compliance as part of routine oversight and respond to member complaints alleging parity violations.

Telehealth as a network supplement

DCH permits CMOs to count contracted telehealth providers toward network adequacy in many service categories, particularly in rural and shortage areas. Telehealth has been a key tool for closing behavioral health network gaps. Telehealth does not substitute for in-person network in all categories (for example, dental procedures and certain specialty exams require in-person providers).

Sanctions and enforcement

DCH has multiple tools for enforcing CMO compliance with the quality framework:

• Liquidated damages: Contractually specified financial penalties for specific performance failures (for example, $X per day for failure to meet a specified reporting deadline)
• Corrective Action Plans (CAPs): Required CMO remediation with deadlines, milestones, and DCH-approved corrective steps
• Civil money penalties: For certain violations under Section 1903(m)(5) of the Social Security Act
• Temporary management: CMS or state-appointed leadership to direct the CMO during severe noncompliance
• Enrollment freezes: CMO cannot accept new members until problems are corrected
• Suspension of capitation payments: DCH stops paying the CMO pending correction
• Mandatory member auto-assignment changes: DCH steers new auto-assignments away from a noncompliant CMO
• Contract termination: The ultimate sanction, with members transferred to other CMOs

CMS has concurrent authority and can impose sanctions independently.

Worked examples: how the framework plays out

Marcus, 42, Atlanta, diabetes management and HEDIS-driven care

Marcus is 42 years old and lives in southwest Atlanta. He has type 2 diabetes with an A1c of 9.2 percent, hypertension, and early kidney disease. He is enrolled in Amerigroup. The HEDIS CDC measure (Comprehensive Diabetes Care) is one of Amerigroup's withhold-tied performance metrics. The CDC measure includes indicators for HbA1c testing, HbA1c control below 8 percent, eye exam, blood pressure control, and medical attention for nephropathy.

Amerigroup's care management team identifies Marcus as a member with uncontrolled diabetes and assigns him a care manager. The care manager calls Marcus to verify his primary care provider, check on his medications, schedule a retinal eye exam at the in-network optometrist, schedule a follow-up with his primary care for blood pressure and medication adjustment, and offer enrollment in Amerigroup's diabetes self-management program. Marcus's care manager also coordinates a referral to a registered dietitian and to a community-based diabetes education program.

Over the next 90 days, Marcus's A1c drops to 8.1 percent, his blood pressure improves to 135/85, and he completes his eye exam. Amerigroup counts Marcus in the numerators of multiple CDC sub-measures. The aggregate CDC performance improvement across thousands of members like Marcus contributes to Amerigroup hitting its CDC withhold target, which means Amerigroup earns back the withheld capitation dollars rather than forfeiting them.

Marcus is also able to compare CMO CDC performance across the four Georgia CMOs by looking at the most recent EQRO Annual Technical Report on the DCH website. If he found that another CMO had substantially better CDC performance, he could switch during the annual open enrollment.

Aisha, 28, Macon, prenatal care timeliness

Aisha is 28 years old and lives in Macon. This is her first pregnancy. She enrolls in Medicaid Pregnancy Coverage at 9 weeks and selects Peach State Health Plan as her CMO based on her existing relationship with her primary care provider, who is in the Peach State network.

The HEDIS PPC measure tracks two indicators: timeliness of prenatal care (first prenatal visit in the first trimester or shortly after enrollment) and postpartum care (a visit within an appropriate postpartum window). Peach State has a Performance Improvement Project on prenatal care timeliness in Macon and the surrounding region, where historical timeliness has lagged the state average.

Within 5 business days of Aisha's enrollment, Peach State's maternal care management team calls to verify her pregnancy, confirm her OB choice, schedule her first prenatal visit, arrange non-emergency medical transportation if needed, and provide written and verbal information about prenatal care, the WIC program, dental coverage during pregnancy, and behavioral health screening. Aisha attends her first prenatal visit at week 11, well within the first trimester. Peach State counts Aisha in the PPC timeliness numerator.

After Aisha delivers at 39 weeks, Peach State's postpartum outreach team calls within 5 days to congratulate her, schedule her postpartum visit, ensure her newborn is enrolled in Medicaid through deeming, and offer postpartum coverage extension options. Aisha attends her postpartum visit at week 5. Peach State counts Aisha in the PPC postpartum numerator.

The aggregate PPC improvement across Peach State's pregnant member population contributes to Peach State meeting its PPC withhold targets and to Peach State's PIP achievement. The EQRO Annual Technical Report publishes Peach State's PPC scores against the other three Georgia CMOs.

Jamil, 14, Savannah, ADHD and follow-up after psychiatric hospitalization

Jamil is 14 years old and lives in Savannah. He has ADHD and major depression. He is enrolled in CareSource Georgia. After a suicidal ideation episode, Jamil is admitted to an inpatient psychiatric unit for 6 days. The HEDIS FUH measure (Follow-Up After Hospitalization for Mental Illness) tracks 7-day and 30-day post-discharge follow-up with a mental health provider.

CareSource's discharge planning team and behavioral health care manager coordinate with the inpatient unit during Jamil's admission. Together they schedule his 7-day follow-up appointment with his outpatient psychiatrist before he is discharged. The appointment is scheduled by telehealth because the local in-person psychiatrist's next opening is 4 weeks out, and CareSource's network adequacy analysis shows that telehealth is the only way to meet the 7-day FUH numerator within the CMS-2439-F outpatient mental health appointment access standard.

Jamil attends his 7-day appointment by telehealth. He also attends a 21-day follow-up with his therapist, meeting the 30-day FUH numerator. CareSource counts Jamil in both FUH sub-measures.

When Jamil's family later requests a partial hospitalization program (a higher level of behavioral health care between outpatient and inpatient), CareSource's utilization management denies the request based on criteria the family disputes. Jamil's mother files an appeal with CareSource within the required timeframe, requests expedited review based on the severity of Jamil's symptoms, and requests aid paid pending. CareSource's expedited review process resolves promptly and upholds the denial. Jamil's mother then files a State Fair Hearing request with the Office of State Administrative Hearings. The ALJ hears the case at 28 days post-filing, reviews CareSource's medical necessity criteria, and finds that the criteria were misapplied. The ALJ orders CareSource to approve the partial hospitalization program. The decision is issued as final agency action, and Jamil begins the program the following week.

Diana, 60, dually eligible, Albany, plan coordination and switching

Diana is 60 years old and lives in Albany. She is dually eligible for Medicare and Medicaid. She is enrolled in a Medicare Dual Eligible Special Needs Plan (D-SNP) for her Medicare benefits and in Wellpoint Georgia for her Medicaid benefits, which cover Medicare cost-sharing, certain services not covered by Medicare, and the additional supports she needs.

Diana experiences a coverage gap during a hospital admission. Her Medicare D-SNP authorizes the inpatient stay, but a coordination breakdown with Wellpoint Georgia results in Wellpoint refusing to authorize the post-acute skilled nursing facility stay that Diana's discharge plan requires. The skilled nursing facility says they cannot admit Diana without managed care authorization. Diana's daughter calls Wellpoint and the D-SNP repeatedly but cannot resolve the issue.

Diana's daughter files a grievance with Wellpoint about the coordination failure. The grievance triggers a Wellpoint care manager review, which identifies that Wellpoint should have coordinated with the D-SNP under the dual eligible coordination protocols. Wellpoint apologizes for the breakdown and approves the skilled nursing facility stay retroactively.

Diana also exercises her right to switch CMOs for cause based on the coordination failure. Wellpoint's failure to coordinate with the D-SNP is, in Diana's view, a service quality issue that justifies a cause-based switch outside the open enrollment window. Diana's daughter files the cause-based switch request with DCH, providing documentation of the grievance and the coordination failure. DCH approves the switch and Diana moves to Amerigroup, which has stronger documented D-SNP coordination protocols.

Tyrell, 19, Atlanta, former foster youth, grievance and appeal

Tyrell is 19 years old and lives in Atlanta. He aged out of foster care at 18 and now has automatic Medicaid coverage through age 26 under ACA Section 2004. He is enrolled in Amerigroup under the Georgia Families 360 degrees program for former foster care youth.

Tyrell has anxiety and PTSD related to his time in foster care. His caseworker recommends a specific psychiatrist who specializes in trauma in young adults. Tyrell tries to schedule with that psychiatrist through the Amerigroup provider directory but finds that the directory listing is out of date: the psychiatrist's practice is full and has been for 6 months. Tyrell tries three other psychiatrists from the directory, finding that two have left the network and the third has a 9-week wait, well in excess of the CMS-2439-F standard for outpatient mental health access.

Tyrell files a grievance with Amerigroup about the provider directory inaccuracy and the appointment wait time. Amerigroup's grievance team escalates to network management. Network management arranges an expedited appointment with an in-network psychiatrist via telehealth at 4 business days, and initiates a directory accuracy review and update.

Separately, Tyrell's psychiatrist requests authorization for an intensive outpatient program. Amerigroup denies the request as not medically necessary. Tyrell files an appeal within the 60-day window and requests aid paid pending (in this case there are no existing authorized services to continue, so aid paid pending does not apply). The appeal review by a clinical peer overturns the denial. The intensive outpatient program is authorized.

Sarah, 45, rural Augusta area, network adequacy and secret shopper

Sarah is 45 years old and lives in a rural county in the Augusta area. She has type 2 diabetes with diabetic retinopathy and needs ongoing endocrinology care. She is enrolled in CareSource Georgia.

The CareSource provider directory lists three in-network endocrinologists within reasonable distance: two in Augusta and one in a nearby town. Sarah calls all three. The two Augusta endocrinologists' practices are closed to new patients. The nearby endocrinologist has a 6-month wait.

Sarah files a grievance with CareSource about the directory inaccuracy. Coincidentally, the DCH-contracted secret shopper survey vendor calls Sarah's three endocrinologists the same week as part of the annual CMS-2439-F validation. The vendor confirms that two are not accepting new patients and the third has a 6-month wait. The vendor's findings feed into the DCH annual access report, which identifies CareSource as having a network adequacy deficiency in endocrinology in Sarah's region.

DCH requires CareSource to implement a Corrective Action Plan including contracting at least one additional in-network endocrinologist, offering telehealth endocrinology with an in-network provider in Atlanta, and reimbursing transportation to in-person endocrinology visits at the nearest available endocrinologist. CareSource implements all three steps. Sarah is seen by a telehealth endocrinologist within 2 weeks for her first visit, and CareSource provides reimbursable transportation for her annual in-person diabetic retinopathy exam.

Practical guidance for Georgia Medicaid families

How to use HEDIS and CAHPS data

Visit the DCH website (dch.georgia.gov) and search for the most recent EQRO Annual Technical Report. The report typically runs 200 to 400 pages and includes detailed performance data for each of the four CMOs. The executive summary will highlight the most important findings. For specific measures relevant to your situation (for example, PPC if you are pregnant, FUH if you have a family member with serious mental illness, CDC if you have diabetes), look up each CMO's score and the percentile rank against national Medicaid plan benchmarks.

For member experience, look up CAHPS scores in the same report. Pay attention to global ratings (Rating of Personal Doctor, Rating of Health Plan) and to composite scores most relevant to your situation (Getting Needed Care if you have ongoing needs, Customer Service if you anticipate frequent interactions).

For NCQA accreditation, visit ncqa.org and look up each Georgia CMO. Note the accreditation level and the most recent rating.

How to file a grievance

You can file a grievance with your CMO at any time. Contact your CMO's member services line (Amerigroup 1-800-600-4441, CareSource 1-855-202-0729, Peach State 1-800-704-1484, Wellpoint 1-800-300-8181) and tell them you want to file a grievance. You can also file in writing to the CMO's grievance department. Keep a written record of the date, time, the staff member you spoke with, and what was said. The CMO must acknowledge your grievance and provide a written response within 90 calendar days.

If your grievance is not resolved to your satisfaction, you can escalate to DCH at 1-866-211-0950, file a complaint with the Georgia Office of the Commissioner of Insurance at 1-800-656-2298, or seek free legal help from Georgia Legal Services Program at 1-833-457-7529.

How to file an appeal

When you receive a Notice of Adverse Benefit Determination from your CMO, read it carefully. Note the date, the action being taken, the reason, and the deadline for filing an appeal. If the action is a termination, suspension, or reduction of a previously authorized service, request aid paid pending promptly when filing.

File the appeal with your CMO orally (by calling member services) or in writing. Note that you may want both: call to start the clock and follow up with written documentation. Request expedited review if standard timeframes could harm your health. Request aid paid pending if applicable.

If the CMO upholds the denial, you have the right to a State Fair Hearing. File the State Fair Hearing request with DCH within the required filing window after the CMO's final appeal decision.

For complex appeals (especially behavioral health, durable medical equipment, or denied surgeries), consider engaging a free legal advocate at Georgia Legal Services Program (1-833-457-7529) or, in metropolitan Atlanta, Atlanta Legal Aid Society (404-524-5811).

How to switch CMOs

Within 90 days of initial enrollment, call Georgia Families Enrollment at 1-888-423-6765 and request a switch to another CMO. No cause required.

During annual open enrollment (typically in the fall), call Georgia Families Enrollment to change CMOs.

At any time for cause, call Georgia Families Enrollment to file a cause-based switch request. Be prepared to document the cause (denied service, unresolved network issue, ongoing quality problem, move outside service area, etc.).

How to use the brevy.com resources

Brevy.com publishes comprehensive guides covering Georgia Medicaid managed care, the four Georgia CMOs, the appeals and fair hearings process, behavioral health coverage, pregnancy coverage, EPSDT, telehealth, the Pathways to Coverage Section 1115 demonstration, the Georgia Families 360 degrees program for foster youth, and many more eldercare and Medicaid topics. The brevy.com guides are written for Georgia families navigating these complex systems and reference the federal authorities, state regulations, contract provisions, and operational details that determine how the system actually works for real members.

Frequently asked questions

::accordion ::accordion-item{title="What is a CMO and which CMO am I enrolled in?"} A Care Management Organization is the name Georgia uses for a Medicaid managed care plan. Georgia has four CMOs: Amerigroup Community Care, CareSource Georgia, Peach State Health Plan, and Wellpoint Georgia. To find out which CMO you are enrolled in, check your Medicaid insurance card, your enrollment confirmation letter, or call DCH Medicaid Member Services at 1-866-211-0950 or Georgia Families Enrollment at 1-888-423-6765. ::

::accordion-item{title="How can I compare the quality of the four Georgia CMOs?"} The Georgia EQRO Annual Technical Report, posted on the Georgia Department of Community Health website (dch.georgia.gov), publishes HEDIS clinical quality measures and CAHPS member experience scores for each CMO with national benchmarks. NCQA Health Plan Accreditation status and ratings are at ncqa.org. You can also call each CMO's member services line and ask about specific quality metrics. Georgia Families Enrollment at 1-888-423-6765 provides choice counseling and can answer comparison questions. ::

::accordion-item{title="Can I switch CMOs?"} Yes. You can switch CMOs within 90 calendar days of initial enrollment for any reason, during the annual open enrollment period (typically held in the fall) for any reason, or at any time for cause (such as a service quality issue, provider network gap, move outside service area, or religious/cultural reason). To switch, call Georgia Families Enrollment at 1-888-423-6765. For a cause-based switch outside the standard windows, you will need to document the cause. ::

::accordion-item{title="What is HEDIS and why does it matter?"} HEDIS stands for Healthcare Effectiveness Data and Information Set. It is a standardized set of clinical quality measures published by the National Committee for Quality Assurance. HEDIS measures cover dozens of topics including well-child visits, prenatal and postpartum care, diabetes care, blood pressure control, mental health follow-up, cancer screening, immunizations, and asthma management. Each CMO's HEDIS scores are public and comparable. HEDIS scores are tied to Georgia DCH's quality withhold structure, meaning each CMO has a real financial incentive to perform well. You can use HEDIS scores to compare CMOs when choosing or switching plans. ::

::accordion-item{title="What is CAHPS and why does it matter?"} CAHPS stands for Consumer Assessment of Healthcare Providers and Systems. It is a standardized member experience survey developed by the federal Agency for Healthcare Research and Quality. CAHPS surveys ask members to rate their personal doctor, their specialist, their health care overall, their health plan, customer service, getting needed care, getting care quickly, and how well doctors communicate. CAHPS scores complement HEDIS clinical quality measures with member-reported experience data. CAHPS scores are public and comparable across CMOs. ::

::accordion-item{title="What is the difference between a grievance and an appeal?"} A grievance is an expression of dissatisfaction about any matter other than a denial, reduction, or termination of services. Examples include rude staff, long waits at the clinic, billing problems, provider directory errors, and dissatisfaction with quality of care. An appeal is a formal request for review of an adverse benefit determination such as a service denial, a service reduction, a service termination, or a denial of payment for a service. Grievances do not have aid paid pending or a right to a State Fair Hearing. Appeals do. ::

::accordion-item{title="What is aid paid pending and how do I request it?"} Aid paid pending means that your previously authorized services continue while your appeal is being decided. It applies when your CMO is terminating, suspending, or reducing services you were already receiving. To get aid paid pending, file your appeal promptly after the Notice of Adverse Benefit Determination and specifically request continuation of benefits. If the appeal is ultimately denied, you may technically be liable for the cost of services received during continuation, although in practice this is rarely enforced. ::

::accordion-item{title="What is an expedited appeal?"} An expedited appeal is one that the CMO must resolve within an expedited timeframe instead of the standard review period. You can request expedited review when the standard timeframe could seriously jeopardize your life, your physical or mental health, or your ability to attain, maintain, or regain maximum function. Expedited appeals are appropriate for denials of urgent medical or behavioral health services, denials of medications needed for ongoing treatment, or terminations of ongoing services where interruption would cause acute harm. You can request expedited review when filing your appeal. ::

::accordion-item{title="How do I request a State Fair Hearing?"} After your CMO appeal is resolved (or after the required resolution period has passed without resolution), you can request a State Fair Hearing before an Administrative Law Judge of the Georgia Office of State Administrative Hearings (OSAH). File a written request with DCH or OSAH within the required filing window after the CMO's final appeal decision. The hearing is typically held by phone or video, although you can request an in-person hearing. You can attend with a representative, present evidence, and cross-examine the CMO's witnesses. The ALJ issues a written decision and DCH adopts it as final agency action. For complex cases, consider engaging a free legal advocate at Georgia Legal Services Program (1-833-457-7529) or Atlanta Legal Aid Society (404-524-5811). ::

::accordion-item{title="What is network adequacy and what wait times can I expect?"} Network adequacy means that your CMO maintains a provider network sufficient to provide adequate access to all covered services. Under the 2024 CMS Medicaid Managed Care Access Final Rule, enforceable appointment wait time standards apply to routine primary care, OB/GYN, and outpatient mental health and substance use disorder services. If your CMO's network does not meet these standards in your area, the CMO must arrange out-of-network access, telehealth, or expedited scheduling. If you cannot get a timely appointment with an in-network provider, file a grievance with your CMO and consider switching CMOs for cause. ::

::accordion-item{title="Does behavioral health network adequacy work the same as medical network adequacy?"} Yes, and on a parity basis. Under the Mental Health Parity and Addiction Equity Act of 2008, behavioral health network adequacy must be no more restrictive than medical/surgical network adequacy. This means appointment wait times, prior authorization requirements, provider density, and out-of-network access for behavioral health must be at least as favorable as for medical/surgical services. CMS and DCH scrutinize parity compliance and respond to member complaints alleging parity violations. ::

::accordion-item{title="What is the EQRO Annual Technical Report and where can I find it?"} The EQRO Annual Technical Report is an annual independent assessment of each Georgia CMO produced by an External Quality Review Organization under contract to the Georgia Department of Community Health. The report validates each CMO's HEDIS measures, validates each CMO's Performance Improvement Projects, presents CAHPS member experience survey results, assesses information systems capabilities, reviews network adequacy, validates encounter data, and identifies areas for improvement. The report is publicly posted on the DCH website (dch.georgia.gov) and is the single best source for comparing CMO quality performance. ::

::accordion-item{title="What if my CMO is failing me and nothing seems to work?"} Multiple escalation paths exist. First, file a grievance with the CMO and request a formal response. Second, escalate to DCH Medicaid Member Services at 1-866-211-0950 or the DCH Office of Inspector General at 1-866-435-7544. Third, file a complaint with the Georgia Office of the Commissioner of Insurance at 1-800-656-2298. Fourth, contact Georgia Legal Services Program at 1-833-457-7529 for free legal advocacy. Fifth, switch CMOs for cause by calling Georgia Families Enrollment at 1-888-423-6765. For complex appeals, request a State Fair Hearing with the Office of State Administrative Hearings. ::

::accordion-item{title="Can I see how often appeals are overturned?"} Yes. The EQRO Annual Technical Report and DCH public reports publish appeal volumes, dispositions, and overturn rates by CMO. Overturn rates vary by CMO and by category of denial. Behavioral health and pharmacy denials are sometimes overturned at higher rates than medical/surgical denials. The data informs DCH oversight and CMO improvement work. Members concerned about a denial can consult the overturn data to understand patterns at their CMO. :: ::

Contact directory

::cta{title="Get help with Georgia Medicaid managed care quality" body="The phone numbers below connect you to the agencies and organizations that can help you compare CMOs, file a grievance, appeal a denial, request a State Fair Hearing, or escalate a complaint. Free legal help is available for Medicaid members." primary="Call DCH Medicaid Member Services 1-866-211-0950"}

• DCH Medicaid Member Services: 1-866-211-0950
• Georgia Families Enrollment (choice counseling, plan switching): 1-888-423-6765
• Amerigroup Community Care Member Services: 1-800-600-4441
• CareSource Georgia Member Services: 1-855-202-0729
• Peach State Health Plan Member Services: 1-800-704-1484
• Wellpoint Georgia Member Services: 1-800-300-8181
• NCQA Customer Support (accreditation lookup): 1-888-275-7585
• Georgia Office of the Commissioner of Insurance and Safety Fire: 1-800-656-2298
• DCH Office of Inspector General (fraud, waste, abuse): 1-866-435-7544
• Georgia Office of State Administrative Hearings (State Fair Hearings): 404-651-7500
• Georgia Legal Services Program (free legal help): 1-833-457-7529
• Atlanta Legal Aid Society: 404-524-5811
• Georgia Council on Aging: 1-866-552-4464
• Healthy Mothers Healthy Babies Coalition of Georgia: 1-800-822-2229 ::

Related Brevy guides on Georgia Medicaid

For more information on Georgia Medicaid topics related to managed care quality, see the following Brevy guides on brevy.com:

• Georgia Medicaid hub at /medicaid/georgia covers the full Georgia Medicaid program including eligibility, enrollment, benefits, and the CMO structure.
• Georgia Medicaid managed care plans at /medicaid/georgia/managed-care-plans provides a detailed plan-by-plan comparison of the four CMOs.
• Georgia Medicaid appeals and fair hearings at /medicaid/georgia/appeals-and-fair-hearings provides a step-by-step walkthrough of the appeal and State Fair Hearing process.
• Georgia Medicaid behavioral health coverage at /medicaid/georgia/behavioral-health-coverage covers the behavioral health benefit including FUH and parity issues.
• Georgia Medicaid pregnancy coverage at /medicaid/georgia/pregnancy-coverage covers prenatal, delivery, and postpartum coverage including PPC HEDIS performance.
• Georgia Medicaid children and EPSDT at /medicaid/georgia/children-and-epsdt covers well-child visits and the EPSDT comprehensive screening benefit.
• Georgia Medicaid telehealth coverage at /medicaid/georgia/telehealth-coverage covers telehealth services and how telehealth supports network adequacy.
• Georgia Medicaid how to apply at /medicaid/georgia/how-to-apply covers enrollment, including CMO choice counseling.

Find personalized help navigating Georgia Medicaid managed care quality at brevy.com.

Disclaimer

This guide is provided for informational purposes only and does not constitute legal, medical, or financial advice. Federal and Georgia state Medicaid law, regulations, contract provisions, and operational guidance change frequently. The information in this guide is current as of the date listed in the page metadata but may become outdated as regulations evolve. For specific questions about your Medicaid coverage, CMO benefits, grievance and appeal rights, or any other Medicaid issue, contact DCH Medicaid Member Services at 1-866-211-0950, your CMO's member services line, Georgia Families Enrollment at 1-888-423-6765, or a free legal advocacy organization such as Georgia Legal Services Program at 1-833-457-7529. The Georgia Department of Community Health, the Centers for Medicare and Medicaid Services, and the four Care Management Organizations are the authoritative sources for current rules and procedures.