Georgia Medicaid Prior Authorization (2026): FFS, CMO, Appeals

The Georgia Medicaid prior authorization process is the utilization-management gate that decides whether a requested service is medically necessary and covered before it is provided. Prior authorization (PA) runs through two pathways depending on whether the member is in fee-for-service or one of the three Georgia Families Care Management Organizations (CMOs). For rating periods that start on or after January 1, 2026, the deciding plan must answer a standard PA request within 7 calendar days and an urgent (expedited) request within 72 hours, under 42 CFR 438.210 and the Centers for Medicare and Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F).1,2 Hold onto one carve-out as you read: CMS-0057-F does not apply to prior authorization decisions for drugs, so a pharmacy request takes a different route through this system than a wheelchair or an imaging order does.2

The federal framework for the Georgia Medicaid prior authorization process

Prior authorization rests on two federal anchors. 42 CFR 440.230(d) lets states place appropriate limits on Medicaid services based on medical necessity or utilization control, the foundation of all Medicaid PA. 42 CFR 438.210 governs PA in managed care, including the decision timelines.

Under 42 CFR 438.210(d), for rating periods that start on or after January 1, 2026, a managed care plan must make a standard service-authorization decision within 7 calendar days of receiving the request, and an expedited decision within 72 hours when the standard timeframe could seriously jeopardize the enrollee's life, health, or ability to attain, maintain, or regain maximum function. (For rating periods that started before January 1, 2026, the prior 14-calendar-day standard cap still applied.) Either clock can be extended by up to 14 calendar days, but on only two conditions and not identically. The standard timeframe may be extended if the enrollee or the provider asks, or if the plan justifies a need for more information and how the delay is in the enrollee's interest. For the expedited 72-hour clock, the regulation names only the enrollee as the one who may request an extension; a provider asking for more time is not one of the two routes the rule allows.1

Two carve-outs inside the same section change which clock applies. Covered outpatient drug authorization decisions are not governed by these timeframes at all: 42 CFR 438.210(d)(3) sends them to the notice rule in Section 1927(d)(5)(A) of the Social Security Act. And if you are a dual eligible enrolled in an applicable integrated plan (the aligned Medicare-Medicaid arrangements defined at 42 CFR 422.561), 42 CFR 438.210(d)(4) requires the decision and notice timelines to follow 42 CFR 422.629 through 422.634 instead, so check those Part C timelines rather than assuming the 7-day and 72-hour figures.1

The most consequential federal change is the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F, finalized 2024), which sets the same operational standards across impacted payers: Medicare Advantage, Medicaid and CHIP fee-for-service, Medicaid and CHIP managed care, and qualified health plan issuers on the federally facilitated exchanges. Two limits run through the whole rule. It does not apply to prior authorization decisions for drugs, and the decision timeframes reach every impacted payer except those exchange issuers. With those limits in place, its operational provisions generally begin January 1, 2026:2

• Standard PA decisions within 7 calendar days and expedited (urgent) decisions within 72 hours
• A specific reason stated for each denial
• Public reporting of prior-authorization metrics, with the first CY2025 metrics posted by March 31, 2026
• The Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization APIs (Fast Healthcare Interoperability Resources, or FHIR, based) for electronic submission and tracking, with a separate, later compliance date generally beginning January 1, 2027

The drug carve-out is the one to remember at the pharmacy counter: a request for a drug does not run on the CMS-0057-F clock.2 Federal Medicaid pharmacy law sets its own floor for that request instead.

Federal Medicaid pharmacy law adds two floors of its own. Under Social Security Act Section 1927(d)(5) (42 U.S.C. 1396r-8(d)(5)), a state plan may require approval before a covered outpatient drug is dispensed only if its system responds by telephone or other telecommunication device within 24 hours of a PA request, and provides for dispensing at least a 72-hour supply of a covered outpatient drug in an emergency situation. Read these precisely, because both are commonly misread. They are conditions on the state's PA system, not a per-request entitlement a member can invoke at the counter; the 24-hour duty is to respond, which is not necessarily to decide; and the 72-hour supply is triggered by an emergency situation as the Secretary defines it, not by a prior authorization being slow or unobtainable, and does not reach the classes of drugs a state may exclude under Section 1927(d)(2). The statute speaks to the state plan; the sources here do not address whether these same conditions bind a CMO's own pharmacy PA, so check that plan's standards.5

The two PA pathways: FFS and CMO

Georgia Medicaid splits prior authorization into two operational pathways based on whether the member is enrolled in fee-for-service (FFS) or in one of the three Georgia Families CMOs.

Fee-for-service pathway

A meaningful share of Georgia Medicaid beneficiaries remain in fee-for-service, including most long-term-care residents in nursing facilities, participants in Georgia's Section 1915(c) HCBS waivers (among them the Elderly and Disabled Waiver Program, or EDWP, which contains the CCSP and SOURCE service-delivery models rather than being separate waivers; the Independent Care Waiver Program, or ICWP; the New Options Waiver, or NOW; and the Comprehensive Supports Waiver Program, or COMP), dual eligibles for Medicaid wrap-around services, and certain medically complex populations.6 Pull current FFS enrollment shares from DCH before relying on a specific percentage.

PA for these beneficiaries is processed by:

• Gainwell Technologies (Georgia Medicaid Fiscal Agent): handles PA for medical/surgical services, durable medical equipment, inpatient (in coordination with the QIO), outpatient, and most non-pharmacy FFS services through the Georgia Medicaid Management Information System (GAMMIS). Portal: gammis.com. Phone: 1-800-766-4456. Fax: 1-866-211-6916.
• OptumRx (FFS Pharmacy Benefits Manager): OptumRx is the PBM for the Georgia Medicaid fee-for-service outpatient pharmacy program and handles FFS pharmacy PA per DCH; pull the current OptumRx pharmacy PA contacts from the DCH pharmacy provider page.4
• Alliant Health Solutions: Quality Improvement Organization (QIO) for inpatient admission certification and concurrent review.

CMO pathway

The remaining beneficiaries are enrolled in one of the three CMOs, and PA is processed by the CMO's internal utilization-management department. Each CMO maintains its own PA forms, clinical criteria (typically based on InterQual or MCG, customized to Georgia Medicaid requirements), and provider portal for electronic submission. Pharmacy PA for CMO members runs through the member's own CMO and its PBM, not through the FFS PBM. As of 2026 the Georgia Families roster is three CMOs (Amerigroup Community Care, CareSource, and Peach State Health Plan); WellCare is no longer a separate Georgia Families Medicaid CMO. A 2024 reprocurement remains in the protest phase pending issuance of the Notice of Award as of 2026; pending that, DCH has extended the Amerigroup, CareSource, and Peach State contracts through June 30, 2027, so this three-CMO roster is the operative one.3

Standard and expedited timelines under the Georgia Medicaid prior authorization process

The CMS-0057-F final rule and the longstanding 42 CFR Part 438 appeal timeframes together set the operative PA clock. The figures below apply to rating periods that start on or after January 1, 2026.1,7,8,5

Critical practice point: continuation of benefits is the most frequently missed step in Medicaid appeals, but it reaches only one kind of case. It applies where the plan is terminating, suspending, or reducing a service the member was already authorized to receive (a therapy course cut short, a home health episode not renewed, an ongoing drug moved off the list). A denial of a first-time PA request leaves nothing to continue. Where it does apply, 42 CFR 431.230(a) bars the agency from terminating or reducing the service once the member requests a hearing before the date the action takes effect. Miss that date and a separate provision, 42 CFR 431.231, still lets the agency reinstate services where the hearing is requested not more than 10 days after the date of action. Continuation gives way only when both halves of a narrow exception are met: it is determined at the hearing that the sole issue is one of federal or state law or policy, and the agency promptly tells the member in writing that services are ending pending the decision. Neither half alone is enough.9

What requires PA in the Georgia Medicaid prior authorization process

States may place medical-necessity and utilization-control limits on covered services under 42 CFR 440.230(d), and managed care plans authorize services under 42 CFR 438.210; the exact list of services requiring PA updates periodically. Verify current requirements at gammis.com (FFS) or in the relevant CMO provider manual. Operational PA categories include:1

Pharmacy

• Non-preferred drugs on whichever drug list governs the member. Which list that is depends on the member's plan, so check the FFS Preferred Drug List or the member's CMO formulary rather than a statewide one4
• Brand-name drugs when a generic exists
• Specialty pharmacy products (hepatitis C antivirals, oncology, biologics, immunomodulators)
• Opioids beyond initial acute-supply windows
• Buprenorphine for opioid use disorder beyond an initial grace period
• Long-acting injectable antipsychotics, growth hormone, ESAs, and other biologics
• Compounded medications above threshold dollar amounts

Durable medical equipment

Georgia Medicaid runs DME as a tiered framework: basic items (walkers, manual wheelchairs, glucometers, CPAP supplies) need no PA; mid-tier items (hospital beds, mobility scooters, oxygen concentrators) go through streamlined PA; complex items (power wheelchairs Group 2 and above, continuous glucose monitors, bariatric equipment, BiPAP, ventilators, wound-VAC, complex pediatric DME) need full PA. Purchases above the policy threshold and rentals beyond an initial period also need PA; check the current DME policy for dollar thresholds.

Inpatient and acute care

All scheduled or elective inpatient admissions, length-of-stay extensions beyond initial certification, acute inpatient psychiatric care (with concurrent review at defined intervals), inpatient rehabilitation, long-term acute care hospitals, and skilled nursing facility admissions for Medicare-Medicaid duals require PA.

Outpatient procedures

Outpatient surgery above policy dollar thresholds, advanced imaging (MRI, CT, PET) beyond defined frequency, cardiac catheterization, bariatric surgery, spinal surgery, joint replacement, genetic testing, sleep studies, and hyperbaric oxygen.

Behavioral health

Inpatient psychiatric admission, Psychiatric Residential Treatment Facility (PRTF) for under-21, partial hospitalization, intensive outpatient programs beyond initial authorization, Applied Behavior Analysis for autism, therapy sessions beyond standard initial allotments, ECT, and TMS.

Home health and personal care

Home health services beyond an initial episode, private-duty nursing (all hours), personal care services (authorized through the member's care coordinator), and HCBS waiver services (continuous care plan PA through the service coordinator).

Therapy services

Physical, occupational, and speech therapy beyond an initial visit allotment for adults; ABA for autism; cognitive rehabilitation.

Transportation, vision, hearing, dental

NEMT exceptions for out-of-area or specialty needs; air ambulance (always PA outside a true emergency); inter-facility transport. Eyeglasses beyond a standard frame allowance, specialty eyewear, hearing aids, cochlear implants. Adult dental is emergency-only over 21; pediatric orthodontia is EPSDT-funded only where medically necessary.

How to submit a PA request

Peer-to-peer reviews

A peer-to-peer (P2P) review is a clinical discussion between the requesting provider and the CMO's medical reviewer, usually a physician, before a final denial. It is often the fastest route to a reversal, because it happens before the formal appeal clock and turns on clinical judgment rather than paperwork.

All three Georgia CMOs offer P2P. Providers must request it within a short window after the initial denial, which varies by CMO, and the UM department schedules a discussion of roughly 15 to 30 minutes. The outcome is approval, modification (an alternative service, such as less-expensive DME), or the denial upheld. P2P is not an appeal: the internal appeal is a separate, formal process with its own 60-day filing window.

The appeal process under the Georgia Medicaid prior authorization process

Step 1: CMO internal appeal (mandatory for managed care)

Under 42 CFR 438.402, a managed care plan may have only one level of appeal for enrollees, and the member must ordinarily exhaust that internal appeal before requesting a State Fair Hearing. The enrollee may request the appeal either orally or in writing: by phone, by mail to the CMO appeals address (in the denial notice), by fax to the CMO appeals fax (in the denial notice), or online through the CMO member portal.8

You do not have to do this alone. If state law permits and you give written consent, a provider or an authorized representative may request the appeal, file a grievance, or request a State Fair Hearing on your behalf. One exception matters: under 42 CFR 438.420(b)(5) a provider cannot request continuation of benefits for you. That request has to come from you or your authorized representative. Two populations sit outside this rule: non-emergency medical transportation PAHPs under 42 CFR 438.9, and dual eligibles in an applicable integrated plan, whose grievances and appeals run under the Part C rules noted above. And the 60-day limit is the appeal deadline only: you may file a grievance with the plan at any time.8

Key parameters:7

• Filing window: 60 calendar days from the date on the adverse benefit determination notice (42 CFR 438.402(c)(2)(ii))
• Resolution: 30 calendar days for a standard appeal and 72 hours for an expedited appeal, each extendable by up to 14 calendar days (42 CFR 438.408(b) and (c)). Those numbers are ceilings on the timeframe Georgia may set, not a period the plan is entitled to use: 42 CFR 438.408(a) requires the plan to resolve the appeal as expeditiously as your health condition requires
• An extension you did not ask for carries duties: the plan must make reasonable efforts to tell you promptly by phone, must give you written notice of the reason within 2 calendar days, must tell you that you may file a grievance if you disagree with the extension, and must still resolve the appeal no later than the day the extension expires (42 CFR 438.408(c)(2))
• Standard resolution of a grievance, as opposed to an appeal, runs on a separate cap of no more than 90 calendar days (42 CFR 438.408(b))
• Continuation of benefits: you must file on or before the later of 10 calendar days after the plan sends the adverse benefit determination notice, or the intended effective date of the action, and it reaches only an appeal about a previously authorized service being terminated, suspended, or reduced
• Right to review the file: the member can request and receive, free of charge, the case file and the medical-necessity criteria used to make the determination
• Right to submit additional information: written documents, witness statements, and additional medical records

Step 2: State Fair Hearing

After exhausting the internal appeal, the member must be given no less than 90 and no more than 120 calendar days from the date of the CMO's resolution notice to request a State Fair Hearing under 42 CFR 438.408(f); the exact deadline within that band is set by each state, so confirm Georgia's window with OSAH first. Georgia hearings are conducted by the Office of State Administrative Hearings (OSAH).7

• Filing: use the route your CMO's resolution notice names; it carries the binding instructions and your deadline. Reach OSAH at 404-657-2800 or 1-877-809-0007 to confirm receipt. Do not file a hearing request with DCH Medicaid Member Services at 1-866-211-0950, which handles benefits, ID cards, and provider listings10,11
• Hearing and decision: pull OSAH's current procedural rules for its timelines
• Representation: an attorney, advocate, family member, or other person may represent the member. Atlanta Legal Aid Society and Georgia Legal Services Program represent income-eligible beneficiaries free.
• Continuation of benefits: there is a second, far shorter clock here, and it is the one that catches people. Under 42 CFR 438.420(c)(2), continued benefits stop unless you request both the State Fair Hearing and continuation within 10 calendar days after the plan sends its notice of adverse appeal resolution. Take the full 90-to-120-day window to file and you keep the hearing but lose the coverage in the meantime7
• The parties to the hearing include the plan itself, alongside you and your representative (or the representative of a deceased enrollee's estate), so expect the CMO to appear and argue its side7
• Where Georgia offers an external medical review, 42 CFR 438.408(f)(1)(ii) makes it your option and free, independent of both the state and the plan, and never a precondition or a deterrent to the hearing, an extension of any timeframe, or a break in continued benefits7

Step 3: Judicial review

Final OSAH decisions may be appealed to Georgia Superior Court under the Georgia Administrative Procedure Act; confirm the current judicial-review window with counsel before filing. The standard of review is substantial evidence.

Adverse benefit determination notices

Under 42 CFR 438.404, the denial notice must include the adverse benefit determination; the reasons for the decision (specific to the case, not generic), including the right to free copies of the documents and the medical-necessity criteria used; the right to file an appeal and the procedures for doing so; the right to request a State Fair Hearing after the internal appeal; the circumstances under which an appeal can be expedited and how to request it; the right to have benefits continue pending the appeal and how to request continuation; and the member's potential liability if benefits are continued and the determination is upheld.12 Separately, when a plan fails to meet 42 CFR 438.408's notice and timing requirements for resolving an appeal, the enrollee is deemed to have exhausted the internal appeal and may go straight to a State Fair Hearing.7 That turns on how the plan handles the appeal, so file the plan's internal appeal within 60 calendar days of the date on the determination notice either way.8

Common denial reasons and how to respond

1. Lack of medical necessity documentation. The leading cause of initial denial. Reviewers read clinical notes, not check-boxes: send progress notes, imaging, labs, and a narrative tying the diagnosis to the service. For DME add the face-to-face encounter note; for pharmacy, trial-and-failure documentation for the preferred alternatives on the governing list.
2. Failure to trial preferred alternatives. Pharmacy PA wants documented trials of the preferred drugs on the applicable list; DME wants less-expensive alternatives; therapy may want less-intensive services. Submit a trial log with dates, dosages or intensity, response, and why each was stopped.
3. Service exceeds policy limits. Therapy visits over the annual cap, imaging over allowed frequency, opioid days supply over the acute limit. Document medical necessity for the additional units, and cite EPSDT for under-21 to reach past adult caps.
4. Out-of-network provider. Request a single-case agreement, show expertise unavailable in-network, and document the in-network attempts that failed.
5. Member not eligible at date of service. Verify through Gateway; if the member should have been eligible (a procedural termination within the reconsideration window), pursue retroactive reinstatement, then submit the PA.
6. Service not covered for adult population. Adult dental, limited adult vision, hearing aids. For members under 21, cite Early and Periodic Screening, Diagnostic, and Treatment (EPSDT): under Social Security Act Section 1905(r) (42 U.S.C. 1396d(r)), Medicaid must cover any medically necessary service that corrects or ameliorates a condition found through screening, whether or not that service is otherwise covered for adults under the state plan.13
7. Documentation incomplete. A missing face-to-face encounter note, blank PA form fields, absent diagnosis codes. Resubmitting complete is usually the fastest path to approval.
8. Service requires step therapy. Submit the step-therapy documentation; document any contraindication to the preferred alternative, or request a stabilization exception if the patient was already stable on the requested drug.

Worked examples of the Georgia Medicaid prior authorization process

Standard PA: Marcus (49), CareSource, scheduled knee MRI

Marcus's PCP orders an MRI for a suspected meniscal tear after failed conservative treatment (physical therapy, NSAIDs, a knee brace), submitting PA through the CareSource portal with imaging history and clinical notes. The UM nurse reviews the next day, the documentation supports medical necessity, and PA is approved within the standard window.

Expedited PA: Aisha (4), Peach State, home IV antibiotic

Aisha is hospitalized Friday with a cystic fibrosis exacerbation, and the discharge plan is a 14-day IV antibiotic course by home infusion. The hospital case manager submits an expedited PA with a clinical jeopardy attestation. Peach State reviews the next morning and approves within the expedited window; Aisha goes home Monday.

Pharmacy PA: Robert (62), FFS, hepatitis C treatment

Robert is diagnosed with hepatitis C and prescribed Mavyret. As an FFS member, his pharmacy submits to OptumRx; the specialty antiviral requires PA. What protects Robert is the 24-hour rule: the state's PA system must respond within 24 hours of the request. What does not protect him is the 72-hour emergency supply, and this is where families are most often misled. That supply turns on an emergency situation as the Secretary defines it, not on a PA being slow, so a pharmacist cannot hand Robert three days of Mavyret simply because the authorization has not come back. His specialist submits the documentation the next day and the authorization follows.4,5

Denial reversed at peer-to-peer: Sarah (9), Amerigroup, Group 3 power wheelchair

Sarah has spastic quadriplegic cerebral palsy, and a Group 3 power wheelchair is requested with tilt-in-space, custom seating for scoliosis management, and a head array. Amerigroup denies, citing "Group 2 may meet needs." Sarah's PT requests a peer-to-peer within the CMO's window and walks the medical director through the tilt-in-space requirement for pressure relief, the seating for spinal alignment, and the head array for severe upper-extremity involvement. The director agrees Group 3 is medically necessary.

Internal appeal: David (54), CareSource, denied bariatric surgery

David has BMI in the bariatric-surgery range plus T2DM, hypertension, and sleep apnea. CareSource denies the surgeon's PA, citing "medically supervised weight-loss program documentation insufficient." With David's written consent, his surgeon files the internal appeal, adding dietitian records, an exercise log, prior weight-loss attempts, and comorbidity progression. CareSource resolves within the standard 30-day window and approves the laparoscopic gastric sleeve.

State Fair Hearing: Eleanor (78), Amerigroup, denied SNF transfer

Eleanor is hospitalized after a stroke. Discharge is planned to a skilled nursing facility for sub-acute rehab. Amerigroup denies the SNF transfer, citing "skilled rehab can be provided at home with home health agency services." The daughter files an MCO internal appeal; Amerigroup's expedited review upholds the denial. She then files a State Fair Hearing with OSAH. (Continuation of benefits is not available here: the SNF stay was never authorized, so there is no ongoing service to continue.) At the OSAH hearing, PT, OT, and the discharge planner testify that Eleanor's mobility deficits and ADL impairment require 24/7 nursing oversight. The ALJ rules the SNF admission medically necessary; Amerigroup's decision is reversed; Eleanor is admitted to the SNF.

Things commonly missed in the Georgia Medicaid prior authorization process

1. Incomplete clinical documentation, the leading cause of initial denial. The PA form is the cover sheet, not the case.
2. Sending the request down the wrong pathway because no one checked whether the member is fee-for-service or CMO.
3. Missing the peer-to-peer window, which forfeits the fastest route to a reversal.
4. Filing the internal appeal after the 60-calendar-day window, which forfeits appeal rights.
5. Missing either 10-day continuation window, at the denial notice or at the appeal-resolution notice.
6. Forgetting that EPSDT applies the correct-or-ameliorate standard to members under 21, not adult criteria.
7. Keeping no dated record of submissions, faxes, phone confirmations, and notices.

A few more common questions:

Can I keep getting the service while I appeal? Only if you are already receiving it. Continuation of benefits keeps an existing service running while you appeal; it has nothing to continue when the plan is denying a request for a service you have not been authorized to receive yet. Where it does apply, 42 CFR 431.230(a) bars the agency from terminating or reducing the service once you request the hearing before the date the action takes effect; if you miss that date, 42 CFR 431.231 still lets the agency reinstate services where you request the hearing no more than 10 days after the date of action. If you lose, 42 CFR 431.230(b) lets the agency recover the cost of the services furnished solely by reason of that continuation, not everything you received while the appeal was pending. There are two 10-day windows in this process, one at the plan's denial notice and one at its appeal-resolution notice, and between them they are the most frequently missed deadlines in Medicaid appeals. Mark both.9

Does my pharmacy need PA for my medication? That depends on which list covers you, and your enrollment decides that: the fee-for-service program and each Georgia Families CMO run their own list rather than one statewide list, so confirm the current one with your plan. On whichever list governs you, most preferred drugs do not require PA, while non-preferred drugs, brand-name drugs when a generic exists, specialty pharmacy products (hepatitis C antivirals, oncology, biologics), opioids beyond initial acute-supply windows, and certain other categories do. If you are in fee-for-service, that PA goes through OptumRx, the FFS pharmacy benefits manager per DCH. Federal law requires the state's PA system to respond within 24 hours of the request, and separately to allow at least a 72-hour supply in an emergency situation as the Secretary defines it. That emergency supply is not a bridge you can claim just because your authorization is taking too long. If you are in a Georgia Families CMO, your PA goes through that plan and its pharmacy benefit manager under its rules.4,5

My child needs a service the CMO says is not covered. Can EPSDT help? Yes. Under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), Medicaid is required to cover any medically necessary service for children under 21 that corrects or ameliorates a physical or mental condition, including services not generally covered for adults. PA criteria for children must apply this broader correct-or-ameliorate standard. If a CMO denies a service for your child citing standard adult criteria, request EPSDT review or file an appeal.13

Contacts for the Georgia Medicaid prior authorization process

Learn More

Find personalized help navigating the Georgia Medicaid prior authorization process 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.