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

Georgia rates its three Medicaid managed care plans on quality using clinical scores, member surveys, independent reviews, and a five percent capitation withhold. That withhold sits in the model CMO contract, and the state's own reviewers have questioned whether it is enforced. This guide shows Georgia families how to use the data to choose a plan, file a grievance, and appeal a denial.

Most Georgia Medicaid beneficiaries get their coverage through a Care Management Organization (CMO), the term Georgia uses for a Medicaid Managed Care Organization (MCO).1 The three current Georgia CMOs are Amerigroup Community Care of Georgia, CareSource Georgia, and Peach State Health Plan. The Georgia Department of Community Health contracts with these three organizations to deliver benefits, manage provider networks, authorize services, pay providers, and coordinate care. The state pays each CMO a capitated monthly payment per enrolled member, and the CMO bears the financial risk if costs exceed it.2

That payment model creates a built-in tension. A CMO has a financial incentive to limit utilization, which can show up as service denials, narrow networks, slow appeals, and underinvestment in prevention. To counter those incentives, federal Medicaid law and Georgia rules build a quality framework on top of the contract. Federal regulations at 42 CFR Part 438 require each CMO to run a Quality Assessment and Performance Improvement program, undergo an annual independent External Quality Review, meet network adequacy and access standards, and operate a grievance and appeal system that includes continuation of benefits during an appeal and the right to a State Fair Hearing.3 Georgia adds quality withholds tied to performance, Performance Improvement Projects on priority topics, annual member experience surveys, and secret-shopper network validation.

For a Georgia family, this is the machinery behind real outcomes: how a delayed mental health appointment gets scheduled, how a denied ultrasound gets overturned on appeal, how you compare plans before switching, and how a CMO that underperforms loses money.

How Georgia rates Medicaid managed care quality

The federal framework: 42 CFR Part 438

Section 1932 of the Social Security Act, codified at 42 USC 1396u-2, lets states require most Medicaid beneficiaries to enroll in managed care while guaranteeing choice of plans, grievance and appeal rights, and quality measurement. CMS implemented that authority through 42 CFR Part 438.

Part 438 anchors the quality framework in a handful of subparts. 42 CFR 438.330 requires each CMO to run a Quality Assessment and Performance Improvement program, including Performance Improvement Projects, HEDIS-based performance measurement, and mechanisms to detect both under- and overutilization. Under Section 1932(c)(2) and the External Quality Review subpart at 42 CFR 438.350 through 438.364, the state must contract with a qualified External Quality Review Organization (EQRO) for an annual independent review of each CMO and an Annual Technical Report.3 42 CFR 438.402 through 438.424 establish the grievance and appeal system, and 42 CFR 438.6 is the basis for Georgia's quality withhold.

The framework was last overhauled by the 2024 Medicaid and CHIP Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F), published in the Federal Register on May 10, 2024 and effective July 9, 2024, which strengthened enforceable access standards, including maximum appointment wait time standards and independent secret-shopper surveys, and established a Medicaid and CHIP managed care Quality Rating System.5

HEDIS, CAHPS, and the EQRO report

Two instruments drive the public quality picture. The National Committee for Quality Assurance (NCQA) publishes HEDIS, a standardized set of clinical quality measures covering well-child visits, prenatal and postpartum care, diabetes care, blood pressure control, behavioral health follow-up, cancer screening, immunizations, and asthma. The federal Agency for Healthcare Research and Quality develops the CAHPS member experience surveys, which ask members to rate their doctor, their plan, customer service, and how easily they got care.

The EQRO Annual Technical Report is the single best source for comparing the three Georgia CMOs. Produced annually by an independent organization under contract to DCH, it validates each CMO's HEDIS measures and Performance Improvement Projects, presents CAHPS results, assesses information systems, and reviews network adequacy. The report is publicly posted on the DCH website and presents each CMO's scores against national Medicaid benchmarks. Federal law also requires the results of each review to be made available to participating providers, enrollees, and potential enrollees, so a member or someone deciding between plans can ask for a plan's EQR findings directly.3

Quality withholds and performance incentives

The Value-Based Purchasing (VBP) section of the Georgia Families model contract (section 4.12.12 of the 2017 shell) states that "Beginning in Calendar Year (CY) 2017, DCH will withhold five percent (5%) of the Contractor's Capitation Rates" and that "Attachment U outlines the performance measures and related targets that the Contractor must achieve." The payout is all-or-nothing per measure and pro-rata overall: the withhold is allotted equally across fourteen performance targets, and a CMO earns back the share of the withhold matching the share of targets it hits. The contract also requires each CMO to plan for passing half of any incentive payment through to its providers. The measures were HEDIS measures when the contract was written, but the contract reserves DCH's right to change them.6

Read that as leverage written into a contract, not as a guarantee that quality is being bought, and note that the contract text above is the 2017 shell rather than confirmed current terms. Georgia's own Office of Health Strategy and Coordination reviewed the managed care contracts on October 3, 2022, characterized the Attachment U metrics as "primarily related to Healthcare Effectiveness Data and Information Sets (HEDIS) measures," and found that "the financial withhold has not been implemented as described in the contract" and that "the CMOs are performing at or below the HEDIS 25th percentile benchmark."6 So the 5 percent withhold tells you what DCH may do, and the state's own reviewers questioned whether it does it. For a family comparing plans, the EQRO Annual Technical Report is the more reliable signal.

NCQA Health Plan Accreditation

NCQA also offers voluntary Health Plan Accreditation, covering quality and utilization management, credentialing, members' rights, member experience, and population health. Because it is voluntary and status changes, check it rather than assume it: each CMO's current status is public at ncqa.org.

Who runs Georgia Families and the three CMOs

The Georgia Families program is the state's mandatory Medicaid managed care program for most beneficiaries.1 It is administered by DCH under contracts with three current Care Management Organizations:

• Amerigroup Community Care of Georgia, a subsidiary of Elevance Health, member services 1-800-600-4441.1
• CareSource Georgia, the Georgia operation of CareSource, a not-for-profit plan headquartered in Dayton, Ohio, member services 1-855-202-0729.
• Peach State Health Plan, a subsidiary of Centene Corporation, member services 1-800-704-1484.

On December 2, 2024, DCH issued a Notice of Intent to Award under a reprocurement of the Georgia Families contracts, naming a different proposed slate: CareSource Georgia, Humana Employers Health Plan of Georgia, Molina Healthcare of Georgia, and UnitedHealthcare of Georgia, with UnitedHealthcare named the apparent successful plan for the Georgia Families 360 contract. As of September 2026 that procurement is still in the protest phase pending issuance of the Notice of Award, no go-live date is published, and no member transition has occurred; pending that notice DCH is extending the current three-CMO contracts through June 30, 2027, an extension it conditions on the award not issuing, so it can end sooner.1 Until any new slate goes live, the three CMOs above remain the current Georgia Families plans.

Georgia Families covers most beneficiaries, including children, parents, pregnant women, and Pathways adults. Several groups are not in it. DCH's Georgia Families FAQ answers "Who is NOT eligible for Georgia Families?" with four categories: people in a nursing home, people in hospice, Aged, Blind, and Disabled beneficiaries (with certain exceptions), and children in the Georgia Pediatric Program (GAPP). PACE participants are likewise outside it.

That exclusion matters most to the readers this guide is otherwise written for. If you are an older or disabled Georgia Medicaid beneficiary, do not assume you are in a CMO. Check your Medicaid card or call DCH Medicaid Member Services at 1-866-211-09507 and confirm which track you are on, because the steps below govern managed care denials and a fee-for-service denial takes a different route to a state fair hearing.

Two specialized arrangements run alongside the main program. Planning for Healthy Babies (P4HB) provides family planning and interpregnancy care through the CMOs. The Pathways to Coverage Section 1115 demonstration, which launched July 1, 2023 and is temporarily extended through December 31, 2026, covers adults ages 19 through 64 with household income up to 95 percent of the Federal Poverty Level, which the state advertises as up to 100 percent because a 5 percent income disregard is applied, who complete at least 80 hours per month of qualifying activities; Pathways enrollees receive coverage through the three Georgia Families CMOs.8

How to choose or switch your CMO

A new Georgia Families beneficiary can choose any of the three CMOs at enrollment; if they do not, DCH auto-assigns based on prior enrollment, family enrollment, geography, and CMO performance.

A new member is enrolled into a plan automatically and then gets three chances to move:

• Within 90 days of the start date of your health plan, switch to a different plan for any reason, online, by phone, on paper, or in person.
• After a year in the plan. Once you have been in your plan for a year you can change plans, and Georgia Families mails you information about changing at that point.
• In between, you can change only with a special reason and Georgia Families' permission, so be ready to document a service quality issue, a network gap, or a move out of the service area.

Changing your primary care provider is separate and unrestricted: you can change PCPs at any time, as long as the new one is in your plan.4

To compare the three before choosing, use the EQRO Annual Technical Report for HEDIS and CAHPS scores, NCQA accreditation status at ncqa.org, and each CMO's provider directory to confirm your doctors are in network. Georgia Families Enrollment at 1-888-423-6765, or georgia-families.com, provides choice counseling.4

How to file a grievance, appeal, or fair hearing

Grievance versus appeal

Under 42 CFR 438.400, a grievance is a complaint about anything other than an adverse benefit determination: rude staff, long clinic waits, directory errors, billing, transportation. An appeal is a request to review an adverse benefit determination, meaning a denial or limited authorization, a reduction or termination of an authorized service, a denial of payment, or a failure to act in time. Grievances carry neither continuation of benefits nor a right to a State Fair Hearing; appeals carry both.

The Notice of Adverse Benefit Determination

Under 42 CFR 438.404, when a CMO makes an adverse benefit determination, it must send the member timely, adequate written notice explaining the action and the reason for it (including the right to free copies of the documents and medical-necessity criteria used), the right to appeal and how to exhaust the CMO's one level of appeal, the right to request a State Fair Hearing, when an appeal can be expedited, and the right to free interpretation services and to appoint a representative.9 Read this notice carefully and note the filing deadline.

Filing an internal CMO appeal

Under 42 CFR 438.402, the member files the appeal with the CMO within 60 calendar days of the date on the Notice of Adverse Benefit Determination.10 The appeal can be filed orally or in writing. The member need not act alone: where state law permits and with the member's written consent, a provider or an authorized representative may file the appeal, file a grievance, or request a State Fair Hearing on the member's behalf, with one exception, that a provider cannot request continuation of benefits. A managed care plan may have only one level of appeal. The 60-day clock is the appeal deadline only; a grievance can be filed at any time. One group is outside this rule entirely: a dual-eligible enrolled in an applicable integrated plan follows 42 CFR 422.629 through 422.634 instead of the Medicaid managed care appeal rules, so check that plan's timelines rather than these.10

Under 42 CFR 438.408, the CMO must resolve a standard appeal within a state-set timeframe no longer than 30 calendar days, and an expedited appeal within no longer than 72 hours.11 Those federal numbers are ceilings on the state's timeframe, not a period the plan is entitled to use: the rule requires resolution as expeditiously as the member's health condition requires. Either timeframe may be extended by up to 14 calendar days if the member requests the extension or the plan shows the state that more information is needed and the delay is in the member's interest. If the plan extends without your asking, it owes you something: prompt oral notice of the delay, written notice of the reason within 2 calendar days, and notice of your right to file a grievance about the extension itself. A grievance, separately, must be resolved within a state timeframe no longer than 90 calendar days.11 The appeal must be reviewed by someone not involved in the original decision, and a medical-necessity appeal must be reviewed by a clinical peer. If the CMO upholds the denial, it sends a Notice of Appeal Resolution explaining the member's right to 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, which the CMO must resolve within 72 hours.11 Expedited review is 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 when filing.

Continuation of benefits during an appeal

If the appeal involves a termination, suspension, or reduction of a previously authorized service, and the member files the appeal before the action takes effect and requests continuation of benefits, federal law requires the service to continue until a decision is rendered, unless both halves of a narrow exception are met: the hearing determines that the sole issue is one of federal or state law or policy, and the agency promptly tells the member in writing that services will be terminated or reduced pending the decision. Federal rules at 42 CFR 431.230 tie this continuation to a hearing or appeal requested before the date of action; a request made after the action's effective date does not trigger continuation, though 42 CFR 431.231(a) separately lets the agency reinstate services when the request comes no more than 10 days after the date of action. One route is not discretionary at all, and it is the one most often missed. Under 42 CFR 431.231(c), the agency must reinstate and continue services until a hearing decision when all three of these are true: the action was taken without the required advance notice; you request a hearing within 10 days of receiving the notice of action (receipt is presumed 5 days after the notice date unless you show otherwise); and the agency determines the action did not result from applying federal or state law or policy. Someone cut off without advance notice has a right to reinstatement, not merely a hope of it. Do not assume any of this happens by itself: Georgia's DFCS Medicaid manual continues eligibility and patient liability on the member's request when that request arrives within 10 days of the date of timely or adequate notice, and DCH reserves the right to require repayment if the member loses the hearing. Ask for continuation explicitly.12

If the CMO's decision is ultimately sustained, what the agency may claw back is bounded. 42 CFR 431.230(b) permits recovery only of the cost of services furnished solely by reason of the continuation, not of everything the member received while the appeal was pending.12 And under 42 CFR 438.404(b)(6), the notice the plan sends must spell out the circumstances, consistent with state policy, under which a member may be required to pay those costs, so read that paragraph of your notice rather than guessing at your exposure.9

Requesting a State Fair Hearing

After the CMO appeal is resolved, the member can request a State Fair Hearing. A missed deadline opens a second route: under 42 CFR 438.408(f)(1)(i), if the CMO fails to follow its own notice and timing rules, the appeal is deemed exhausted and the member can request a fair hearing without waiting for a resolution that never came.11 Under 42 CFR 438.408(f), the member must request the hearing within the window the state sets, which federal law requires to be no fewer than 90 and no more than 120 calendar days from the date of the CMO's notice of appeal resolution.11 The hearing is a formal proceeding before an Administrative Law Judge of the Georgia Office of State Administrative Hearings (OSAH). It is typically held by phone or video, and the member can attend with a representative, present evidence, and cross-examine the CMO's witnesses. The ALJ issues a written decision that DCH adopts as final agency action, after which the member can seek review in superior court.

How often appeals are overturned

The EQRO Annual Technical Report and DCH public reports publish appeal volumes, dispositions, and overturn rates by CMO. Rates vary by plan and by category of denial. A high overturn rate can signal inappropriate utilization management, and DCH uses appeal data to identify CMOs needing added oversight.

What network adequacy and wait-time standards require

Federal and Georgia standards

42 CFR 438.206 and 438.207 require the state to ensure that each CMO maintains a provider network sufficient to deliver all covered services, addressing time and distance to providers, appointment wait times, specialty access, and accessibility for members with disabilities.13 Georgia sets its own quantitative network time-and-distance standards in the Georgia Families Contract rather than relying on CMS-set figures: each CMO must conduct a geographic access analysis of its network against the standards in Figure 1 of that contract. The federal rule at 42 CFR 438.68 sets the framework but requires the state to develop and enforce the actual quantitative standards. Two federal limbs qualify that. A state may permit an exception to any standard it sets, but the test for granting one has to be written into the plan's contract, and a state that grants an exception must monitor member access to that provider type on an ongoing basis. And appointment wait times are not state-set at the outer bound: the federal rule itself caps routine outpatient mental health and substance use appointments at 10 business days and primary care and OB/GYN appointments at 15.13

Those Figure 1 numbers are public on DCH's network adequacy page, so you do not have to ask anyone for them. Urban members must have two PCPs or pediatricians within eight miles, rural members two within fifteen miles. Obstetric providers: two within thirty minutes or thirty miles urban, forty-five minutes or forty-five miles rural. Specialists, hospitals, mental health providers, general and subspecialty dental providers, therapy (PT/OT/ST) and vision providers: one within thirty minutes or thirty miles urban, forty-five minutes or forty-five miles rural. Pharmacies: one open 24 hours a day, seven days a week within fifteen minutes or fifteen miles urban and thirty minutes or thirty miles rural, and in the rural cell only, a pharmacy with an after-hours emergency phone number and a pharmacist on call also counts. Georgia's compliance bar is that at least 90 percent of the members in each county have access to a provider when the contractual access standards are applied, reported through quarterly CMO Network Adequacy Reports. Where a county falls below 90 percent the CMO must submit a corrective action plan, and DCH says what that plan has to deliver: recruiting additional providers where providers are available, contracting with providers in nearby counties to fill the gap, or coordinating non-emergency transportation, as necessary, so that members receive care. Whether the urban or rural column applies to you is not a matter of impression; DCH classifies each county on the map it publishes on the same page.14

The 2024 CMS appointment wait time standards

Under 42 CFR 438.68(e), added by CMS-2439-F, states must establish and enforce maximum appointment wait time standards: no longer than 10 business days for outpatient mental health and substance use disorder services, 15 business days for primary care, and 15 business days for obstetric and gynecological services. A plan is deemed compliant when independent secret-shopper results show appointment availability meeting those standards at least 90 percent of the time.15 These appointment wait time standards are not yet in force: under 42 CFR 438.68(h), they apply to the first managed care rating period beginning on or after July 9, 2027, and the secret-shopper survey requirement applies on or after July 9, 2028. The network adequacy standard in 42 CFR 438.68(d)(1)(iii) applies to the first rating period beginning on or after July 9, 2026.5

That federal phase-in does not leave Georgia members without an appointment wait-time standard in the meantime. Figure 2 of the Georgia Families Contract already sets contractual waiting times by provider type: routine PCP visits not to exceed fourteen calendar days; adult and pediatric sick visits not to exceed twenty-four clock hours; maternity care not to exceed fourteen calendar days in the first trimester, seven in the second, and three business days in the third; specialists, therapy, and vision not to exceed thirty calendar days; mental health providers fourteen calendar days; routine dental visits twenty-one calendar days and urgent dental care forty-eight clock hours; elective hospitalizations thirty calendar days; urgent care not to exceed twenty-four clock hours; and emergency care immediately, twenty-four hours a day, without prior authorization.14 If your CMO cannot offer you an appointment inside those windows, that is a standard in your plan's contract with the state and you can cite it in a grievance now, without waiting for the 2027 federal date.

The sixty-minute cap on waiting inside the provider's office is a separate standard, and it is not in Figure 2. It sits in Figure 3 of the Georgia Families model contract, Waiting Times by Appointment Type, which caps office waits at sixty minutes for a scheduled appointment and ninety minutes for a work-in or walk-in visit, and requires that after thirty minutes, or forty-five minutes for a work-in or walk-in, the patient be given an update on the wait with the option of waiting or rescheduling. DCH does not republish Figure 3 on its network adequacy page, and the model contract carrying it runs from 2016 to 2017 with renewals to 2020, so those numbers are a decade-old contract generation and are not confirmed against any current DCH publication. Cite the sixty-minute limit to Figure 3, never to Figure 2, and confirm it with your CMO before relying on it.14

Behavioral health parity

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires that financial requirements and treatment limitations for mental health and substance use disorder benefits be no more restrictive than the predominant limits applied to substantially all medical and surgical benefits in the same classification, rather than simply no more restrictive than medical benefits, and it covers prior authorization, medical-necessity rules, and network composition. Medicaid is not a group health plan, so MHPAEA does not reach it directly; a Georgia CMO member's parity rights run through 42 CFR part 438 subpart K, which required compliance no later than October 2, 2017.16,17 A 2024 HHS Office of Inspector General report found that none of the eight states it reviewed had built the required parity terms into their MCO contracts by the October 2, 2017 compliance date. OIG recommended that CMS improve its oversight of states' compliance with parity requirements and require states to improve their own monitoring of MCOs' ongoing compliance; CMS concurred.17 Members who believe a behavioral health benefit is being managed more restrictively than a comparable medical benefit can raise a parity complaint with their CMO and with DCH.

Service authorization timeframes

Under 42 CFR 438.210, a CMO must make a standard prior-authorization decision within a state-set timeframe that may not exceed 7 calendar days for rating periods starting on or after January 1, 2026 (down from the prior 14-day cap), with a possible extension of up to 14 calendar days.18 For an expedited decision, when the standard timeframe could seriously jeopardize the member's life, health, or function, the CMO must decide no later than 72 hours after receiving the request, extendable by up to 14 calendar days only at the member's request or on the plan's justification to the state. Two carve-outs change which clock applies. Covered outpatient drug authorizations are not governed by these timeframes at all. And a dual-eligible enrolled in an applicable integrated plan follows the Medicare Part C timelines at 42 CFR 422.629 through 422.634 instead of the 7-day and 72-hour figures above.18

How DCH enforces Georgia Medicaid managed care quality

DCH has several tools to enforce CMO compliance: liquidated damages for defined performance failures; Corrective Action Plans with deadlines; civil money penalties; enrollment freezes, so the CMO cannot take new members until problems are fixed; suspension of capitation payments; steering new auto-assignments away from a noncompliant CMO; and, as the ultimate sanction, contract termination with members moved to other CMOs. CMS has concurrent authority and can impose sanctions independently.

How the framework plays out: real situations

Diabetes management and HEDIS-driven care

Marcus, 42, lives in southwest Atlanta with uncontrolled type 2 diabetes and early kidney disease, enrolled in Amerigroup. Diabetes care is among the HEDIS measures the contract ties to the VBP withhold, so Amerigroup's care management team flags him, assigns a care manager, and schedules a retinal eye exam, a blood-pressure follow-up, and a diabetes self-management program. He can compare diabetes-care performance across the three CMOs in the EQRO Annual Technical Report, and change plans once he has been in his a year.

Prenatal care timeliness

Aisha, 28, in Macon, enrolls in pregnancy coverage at nine weeks and picks Peach State Health Plan because her OB is in network.19 Georgia Medicaid covers pregnant women through the Right from the Start Medicaid pathway at or below 220 percent of the Federal Poverty Level, measured against a budget group that counts the unborn child, so a single pregnant woman is compared to the two-person limit. Georgia extends postpartum coverage to a full 12 months after the end of pregnancy, and inside those 12 months eligibility holds regardless of changes in income or household. The HEDIS Prenatal and Postpartum Care measure tracks the timeliness of both visits, so Peach State's maternal care team calls within days to confirm her OB, schedule her first visit, and arrange transportation. She is seen at week 11, inside Figure 2's fourteen-day first-trimester standard.

Behavioral health appeal and fair hearing

Jamil, 14, in Savannah, has ADHD and major depression and is enrolled in CareSource Georgia. When his family requests a partial hospitalization program, CareSource denies it as not medically necessary. His mother files an appeal within the 60-day window, requests expedited review, and requests continuation of benefits. After CareSource upholds the denial, she files a State Fair Hearing request with OSAH; the ALJ finds the medical-necessity criteria were misapplied and orders the program approved.

Network adequacy and the secret-shopper survey

Sarah, 45, in a rural county near Augusta, needs ongoing endocrinology care. The three in-network endocrinologists her directory lists are closed to new patients or carry a six-month wait, so she files a grievance about the directory. DCH requires a Corrective Action Plan, and CareSource recruits an additional endocrinologist, adds telehealth, and reimburses transportation, which are the three remedies DCH names. Once the federal secret-shopper requirement takes effect, this kind of gap is independently validated.

Practical guidance for Georgia families

How to file a grievance

You can file a grievance with your CMO at any time. Call member services (Amerigroup 1-800-600-4441, CareSource 1-855-202-0729, Peach State 1-800-704-1484) and say you want to file a grievance, or file in writing, and keep a record of the date, the staff member, and what was said. If it is not resolved, escalate to DCH Medicaid Member Services at 1-866-211-0950, file a complaint with the Georgia Office of the Commissioner of Insurance and Safety Fire at 1-800-656-2298, or seek free legal help from the Georgia Legal Services Program at 1-833-457-7529. GLSP serves the 154 counties outside metro Atlanta and does not represent people living in Clayton, Cobb, DeKalb, Fulton, or Gwinnett; it screens on income generally not more than 200 percent of the federal poverty level, or, the route that matters for an older Georgian, on being aged 60 or older.20,7

How to file an appeal

When you receive a Notice of Adverse Benefit Determination, note the action, the reason, and the deadline. File the appeal with your CMO by phone, to start the clock, and in writing within 60 calendar days. Request expedited review if the standard timeframe could harm your health, and request continuation of benefits, in so many words, if the CMO is ending a service you already receive. If the CMO upholds the denial, request a State Fair Hearing with OSAH. For a complex appeal, consider a free legal advocate at the Georgia Legal Services Program, statewide intake 1-833-457-7529 (1-833-GLSPLAW),7 or, in metro Atlanta, Atlanta Legal Aid Society at 404-524-5811.20

How to switch CMOs

Within 90 days of your health plan's start date, call Georgia Families Enrollment at 1-888-423-6765 (TTY/TDD 1-877-889-4424), Monday to Friday 7 a.m. to 7 p.m., to switch with no reason required. Once you have been in the plan a year, call the same number to change plans. In between, call to request a change with a special reason and be prepared to document it.4

Where to get help with Georgia Medicaid managed care quality

The offices below can help you compare CMOs, file a grievance, appeal a denial, request a State Fair Hearing, or escalate a complaint.

Learn More

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

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.