Georgia Medicaid Third-Party Administrators Guide (2026)

When a Georgia Medicaid family tries to find a dentist who will see their child, schedule a ride to a dialysis appointment, get eyeglasses for a near-sighted second-grader, or pick up a psychiatric medication after switching plans, they encounter a delivery system that is not entirely run by their care management organization. Several major benefit categories are carved out of the CMO capitation contracts and delivered through statewide third-party administrators (TPAs). DentaQuest administers dental services across Georgia. Avesis administers vision services. Modivcare administers non-emergency medical transportation through regional dispatch. Pharmacy benefits flow through pharmacy benefits managers (PBMs) under contract with each Care Management Organization (CMO) and with the Georgia Department of Community Health (DCH) for fee-for-service. This guide explains the TPA infrastructure, who administers each carved-out benefit and under what federal authority, what is covered for children versus adults, how to find providers and schedule trips, and how to escalate when access breaks down.

By Brevy Care Team · Last verified May 12, 2026

The carve-out structure has practical consequences. A Georgia family covered by Amerigroup Georgia Medicaid for medical and behavioral health uses DentaQuest's network and rules for dental, Avesis's network for vision, Modivcare's reservation system for transportation, and Amerigroup's PBM for pharmacy. When a service crosses categories (a dental procedure requiring medical anesthesia, for example, requires coordination between DentaQuest and the medical CMO), navigation gets harder. The carve-outs also reflect Georgia's policy choices about adult coverage scope. Under the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) mandate, children under 21 receive comprehensive dental and vision. Adult dental and vision are optional, and Georgia has chosen to cover them narrowly. Non-emergency medical transportation, by contrast, is a federally required benefit for all Medicaid beneficiaries, and Georgia must ensure adequate NEMT access regardless of age.

This guide walks through Georgia's TPA infrastructure for families and advocates. It explains who administers each carved-out benefit and under what federal authority, what is covered for children versus adults, how to find a provider in each TPA network, how to schedule NEMT trips and resolve common scheduling and quality issues, how the pharmacy benefits manager structure operates under the CMO contracts, what the Pathways to Coverage demonstration's limited-benefit scope means for carved-out services, how postpartum coverage expansion preserves benefits for the postpartum window after delivery, how dual eligibles coordinate between Medicare and Medicaid for these benefits, and how families can escalate when access breaks down.

The Carve-Out Structure of Georgia Medicaid Third-Party Administrators

Georgia Medicaid operates a hybrid delivery model. The Georgia Medicaid Care Management Organizations (CMOs) hold full-risk capitation contracts for medical and behavioral health services under federal Medicaid managed care authority. But several benefit categories are carved out: dental, vision, non-emergency medical transportation, and pharmacy. These carved-out benefits are administered through specialized contractors that serve all Medicaid populations (CMO members, fee-for-service members, and in some cases Pathways to Coverage enrollees).

The rationale for carve-outs varies by benefit. Dental and vision carve-outs allow specialized administration with networks of dental and optometric providers who operate separately from the medical provider community. NEMT carve-outs centralize regional dispatch and contracting with transportation providers, achieving economies of scale and standardized service levels. Pharmacy carve-outs to PBMs allow for specialized formulary management, rebate negotiation, and prior authorization administration.

The carve-out structure creates clear delineations but also creates coordination challenges. When a child needs general anesthesia for extensive dental work, the dental treatment is DentaQuest's responsibility but the anesthesia and surgical center are CMO responsibilities. When a patient transitions from inpatient hospital care to home with NEMT for follow-up appointments, multiple administrative systems must coordinate. When a pharmacy claim crosses pharmacy and medical (such as long-acting injectable antipsychotics that are billed as medical Part B-equivalent for dual eligibles), authorization can fall through the cracks. For Georgia families, knowing which TPA administers which benefit and how to contact each is essential.

Dental Third-Party Administrator: DentaQuest

DentaQuest is the statewide dental third-party administrator under contract with DCH. DentaQuest serves Georgia Families CMO members, fee-for-service Medicaid members, and PeachCare for Kids enrollees through a single dental network of general dentists, pediatric dentists, oral surgeons, periodontists, endodontists, prosthodontists, and orthodontists.

For children under 21, EPSDT requires comprehensive dental coverage. DentaQuest's pediatric dental benefit includes:

• Preventive services: comprehensive oral examinations, routine cleanings, fluoride treatments, sealants, oral health education.
• Diagnostic services: X-rays (bitewings, periapical, panoramic when indicated), comprehensive periodontal evaluation.
• Restorative services: amalgam and composite fillings, stainless steel crowns for primary teeth, permanent crowns when clinically indicated.
• Endodontic services: pulpotomy for primary teeth, root canal therapy for permanent teeth when clinically indicated.
• Periodontal services: periodontal evaluation and treatment when indicated.
• Prosthodontic services: limited; partial or full dentures only when clinically indicated.
• Oral surgery: extractions, soft tissue surgery, treatment of oral pathology.
• Orthodontic services: medically necessary orthodontics only (severe malocclusion meeting specific criteria, cleft palate, craniofacial anomalies); cosmetic orthodontics not covered.
• Emergency dental: relief of pain, infection treatment, urgent care.

For adults 21 and over, Georgia's coverage is significantly narrower under optional services authority. Adult dental coverage includes:

• Emergency dental: extractions, abscess drainage, urgent care for relief of pain and infection.
• Limited dentures: partial or full dentures with specific clinical criteria and authorization.
• Pregnancy-related dental: comprehensive dental services during pregnancy and through the 12-month postpartum extension.
• Medically necessary dental: services required as part of broader medical care (dental clearance before cancer chemotherapy or transplant, treatment of dental complications of diabetes).
• Aged Blind Disabled (ABD) dental: some additional dental coverage beyond standard adult Medicaid in specific clinical situations.

Routine adult dental (cleanings, exams, restorations) is not covered for non-pregnant, non-ABD adults under Georgia Medicaid. To find a dentist, members can use DentaQuest's online provider directory at dentaquest.com or call DentaQuest member services at 1-844-987-0628. Providers can be searched by city, county, ZIP code, and specialty. To file a dental claim or appeal, members can work through their dental provider's office (claims are submitted by the provider in most cases) and through DentaQuest's appeal process.

Vision Third-Party Administrator: Avesis

Avesis is the vision third-party administrator. Avesis manages a network of optometrists, ophthalmologists, and optical labs across Georgia, with varying density by region (urban areas have more participating providers than rural).

For children under 21, EPSDT requires comprehensive vision coverage. Avesis's pediatric vision benefit includes:

• Annual comprehensive eye exams.
• Eyeglasses every 12 months, with replacement for loss or damage.
• Contact lenses when medically necessary (for high refractive error or specific medical conditions).
• Vision therapy when medically indicated.
• Treatment of eye diseases and conditions.

For adults 21 and over, Avesis's vision benefit is limited under optional services authority. Adult vision coverage includes:

• Diabetic eye exams (typically annual for individuals with diabetes).
• Glaucoma screening.
• Cataract surgery and post-cataract eyeglasses.
• Vision rehabilitation services for low vision conditions.
• Treatment of eye diseases and medical eye conditions.
• Other medically necessary eye services.

Routine eye exams and eyeglasses for healthy adults are not covered. To find a vision provider, members can use Avesis's online directory at avesis.com or call Avesis member services at 1-855-214-6777.

Non-Emergency Medical Transportation Third-Party Administrator: Modivcare

Non-emergency medical transportation (NEMT) is a federally required Medicaid benefit. Federal Medicaid law requires states to provide necessary transportation to and from medical care for beneficiaries who have no other means. This is one of the most-used benefits in Medicaid because so many beneficiaries face transportation barriers to medical care.

In Georgia, NEMT is administered through Modivcare. Modivcare absorbed the prior brokers that previously managed Georgia NEMT through corporate consolidation; the company now operates under the Modivcare brand across the state. Georgia is divided into multiple service regions, each with its own dispatch operations and contracted transportation provider networks.

Eligible trips include transportation to:

• Medical appointments at covered providers (primary care, specialty care, behavioral health, dental, vision).
• Pharmacy in some cases (typically when no alternative exists).
• Dialysis (with standing schedule on file).
• Hospital discharge to home or to a step-down facility.
• Therapeutic services (occupational therapy, physical therapy, speech therapy).
• Specialty diagnostic services (laboratory, imaging).

Transportation modes include:

• Ambulatory transport: sedan or van for members who can transfer themselves. Shared rides are common for ambulatory transport.
• Wheelchair-accessible transport: vehicles equipped with wheelchair lifts or ramps for members who cannot transfer to a regular seat.
• Stretcher transport: for non-emergency stretcher transfers (between facilities or for medically fragile patients who cannot sit upright); requires specific medical authorization.
• Public transit pass: in urban areas with public transit, members may receive a bus pass.
• Mileage reimbursement: for members or family members driving their own vehicle to medical appointments, reimbursement at the federal rate may be available.

Advance notice requirements vary by trip type. Routine appointments require multiple business days of advance notice; urgent appointments require shorter notice; same-day reservations are possible for dialysis (with a standing schedule on file with Modivcare) and for hospital discharge. Consult the current Modivcare Georgia member handbook for the operative advance-notice windows.

To reserve a trip, members call Modivcare member reservations. They will need their Medicaid ID number, the appointment date, time, and address, the provider name, their pickup address, return trip needs, and any mobility or accessibility needs. For active trip issues (driver not arriving, wrong vehicle, late driver), members can call Modivcare ride assist. DCH Transportation Services Unit provides state-level oversight and can address complaints not resolved through Modivcare directly.

Pharmacy Benefits Managers Under Georgia Medicaid

Pharmacy benefits administration in Georgia Medicaid is split between the CMOs (for managed care members) and DCH (for fee-for-service members), with each entity contracting with one or more PBMs.

Amerigroup Georgia, CareSource Georgia, Peach State Health Plan, and Wellpoint each contract with a PBM (Express Scripts, OptumRx, CVS Caremark, or comparable) for pharmacy administration. DCH's fee-for-service pharmacy contract is awarded through competitive procurement and changes periodically. For current PBM assignments, consult the Amerigroup Georgia, CareSource Georgia, Peach State Health Plan, and Wellpoint member portals or the DCH Member Handbook.

PBMs administer the pharmacy benefit by:

• Managing the network of participating retail pharmacies, mail-order pharmacies, and specialty pharmacies.
• Processing pharmacy claims in real time at the point of sale.
• Administering the Preferred Drug List and prior authorization programs.
• Operating the prescriber and member call centers.
• Coordinating with manufacturers on rebate agreements.
• Implementing utilization management programs (step therapy, quantity limits, refill-too-soon edits).
• Managing specialty drug logistics including limited distribution networks.
• Coordinating with the Medicare Part D plans for dual eligibles.

EPSDT Pediatric Mandate Driving Comprehensive Coverage

The Early and Periodic Screening, Diagnostic, and Treatment benefit is the legal foundation for comprehensive children's coverage in Medicaid. EPSDT requires that every Medicaid-eligible child under 21 receive periodic comprehensive screening, vision services including eyeglasses, dental services, hearing services including hearing aids, and "all medically necessary services to correct or ameliorate defects, physical or mental illness, and conditions discovered."

The phrase "to correct or ameliorate" is interpreted broadly. CMS has consistently held that any service Medicaid can cover under the broad definition of medical assistance must be provided to children when medically necessary, even if the service is not part of the state's adult benefit package. This means:

• Dental coverage for children is comprehensive even though adult dental in Georgia is limited.
• Vision coverage including eyeglasses for children is comprehensive even though adult vision is limited.
• Hearing aids and hearing services for children are covered.
• Behavioral health services for children including residential treatment when medically necessary are covered.
• Durable medical equipment for children is covered when medically necessary.

EPSDT periodicity schedules are typically based on Bright Futures (American Academy of Pediatrics) for medical screenings, American Academy of Pediatric Dentistry guidelines for dental, and American Optometric Association guidelines for vision. Children receive periodic age-appropriate comprehensive screenings, with treatment of any conditions identified. For Georgia families with Medicaid-eligible children, EPSDT is the basis for the comprehensive dental and vision coverage that DentaQuest and Avesis administer.

Adult Dental and Vision in Georgia

Adult dental and adult vision are optional services in Medicaid. States have wide discretion about what to cover. Georgia has chosen narrow coverage:

For adult dental, Georgia covers emergency dental, limited dentures, pregnancy-related dental, and dental medically necessary for broader medical conditions. Routine cleanings, exams, and restorations are not covered for non-pregnant, non-ABD adults.

For adult vision, Georgia covers diabetic eye exams, glaucoma screening, cataract surgery and post-cataract eyeglasses, vision rehabilitation for low vision, and other medically necessary eye services. Routine eye exams and eyeglasses for healthy adults are not covered.

These coverage limits reflect budget and policy choices, not federal requirements. Several states cover adult dental more comprehensively; Georgia has chosen a narrower approach. The pregnancy expansion is one of the most consequential carve-outs from the general adult limitations. Pregnant Medicaid members receive comprehensive dental services during pregnancy and through the 12-month postpartum extension. This means a pregnant woman can receive cleanings, fillings, periodontal treatment, and other comprehensive dental services through DentaQuest during pregnancy and for the full postpartum window. Vision and other benefits are similarly preserved through the postpartum period. For families with adult members who lack comprehensive dental and vision coverage, supplementation through Federally Qualified Health Centers (FQHCs), community dental clinics, sliding-scale dental schools, and private dental insurance is sometimes available.

NEMT in Operation

NEMT is heavily used in Georgia Medicaid and is frequently the source of family frustration when access breaks down. Common problems include:

• Late or no-show drivers, particularly during peak demand times.
• Inappropriate vehicles (a sedan dispatched for a member who requires wheelchair-accessible transport).
• Long wait times for return trips after appointments, especially when shared rides are involved.
• Multi-stop routing that lengthens trip times.
• Driver behavior complaints.
• Distance limits for specialty care.
• Cancellation penalties for late cancellations or no-shows by members.
• Denials for non-covered destinations.

For specific clinical scenarios, NEMT operates differently:

• For dialysis, members typically have a standing schedule on file with Modivcare so they do not need to reserve each trip. If the schedule changes, the member or facility should notify Modivcare. Same-day trip issues for dialysis should be addressed through ride assist.
• For hospital discharge, NEMT can typically be arranged same-day with the hospital discharge planner coordinating with Modivcare. Discharge to home and discharge to skilled nursing facility are common scenarios.
• For specialty care at distant providers (a pediatric specialist in Atlanta for a rural Georgia member), longer-distance NEMT is available, sometimes with overnight lodging if the trip is sufficiently long.
• For psychiatric inpatient discharge, NEMT to follow-up appointments is critical for preventing readmission; coordination between the discharging facility, the member, and Modivcare is essential.
• For end-of-life and hospice care, NEMT to hospice-related appointments is available; coordination with the hospice program is necessary.

Members who consistently experience NEMT failures can file complaints with Modivcare, with DCH Transportation Services Unit, and through the state fair hearing process when specific trip denials occur.

CMS Managed Care Access Final Rule 2024

The CMS Medicaid Managed Care Access, Finance, and Quality Final Rule of 2024 strengthened federal access requirements for Medicaid managed care. Key provisions that affect Georgia's TPAs include:

• Appointment wait time standards: CMS established maximum wait times for routine primary care, specialty care, behavioral health, and obstetric/gynecological appointments. States must monitor and report on appointment wait times.
• Provider directory accuracy: states must maintain accurate provider directories with updates required within specified timeframes when providers leave the network or change status.
• Telehealth provision: managed care plans must offer telehealth services for clinically appropriate visits, with state oversight of telehealth network adequacy.
• Secret shopper monitoring: states must conduct or contract for secret shopper studies to assess actual appointment availability against directory information.
• Network adequacy reporting: states must submit detailed network adequacy reports to CMS, with public-facing summaries.
• Stakeholder engagement: states must establish Medical Care Advisory Committees with beneficiary representation and Tribal Technical Advisory Groups where applicable.

These requirements apply primarily to managed care, but Georgia's CMO contracts in turn impose obligations on TPAs operating under sub-contracts. DentaQuest, Avesis, Modivcare, and PBMs operating under Georgia Medicaid all face downstream access obligations. For Georgia families, the 2024 rule means that access problems with TPAs are subject to federal oversight and state accountability mechanisms. Documented patterns of poor access (long appointment waits, inaccurate directories, failed transportation) can be the basis for state and federal action. Consult the current CMS Medicaid managed care rule text for the operative effective dates and the specific Federal Register citation.

Pathways to Coverage and Limited-Benefit Scope

The Georgia Pathways to Coverage 1115 demonstration provides limited-benefit Medicaid coverage to adults aged 19 to 64 at low incomes, conditioned on work or other qualifying activity requirements. Pathways was approved by CMS in 2022 with enrollment beginning the following year; consult the current Georgia Pathways to Coverage portal for current enrollment and benefit terms.

Pathways benefits are narrower than full Medicaid:

• Medical: full medical coverage through the CMOs.
• Behavioral health: included.
• Pharmacy: covered with PDL limitations.
• Dental: limited emergency dental only.
• Vision: limited to medically necessary diagnostic services.
• NEMT: included for transportation to covered services.
• Long-term services and supports: not covered under Pathways (separate Medicaid pathways apply).

Pathways enrollees navigating dental, vision, or transportation should verify benefits through DCH Member Services or the Pathways portal before scheduling. DentaQuest, Avesis, and Modivcare will process claims and reservations consistent with the Pathways special terms and conditions.

Postpartum Extension and Benefit Preservation

Georgia adopted the 12-month postpartum Medicaid coverage extension under federal authority that allows states to extend postpartum coverage. The extension applies to pregnancy-eligibility Medicaid recipients (Pregnancy Medicaid).

Under the 12-month postpartum extension, all benefits including dental, vision, NEMT, and pharmacy are preserved for the full postpartum window after delivery. This creates a substantial expansion from the prior shorter postpartum coverage and creates a year-long window for postpartum health needs including:

• Continued mental health treatment (postpartum depression, postpartum anxiety).
• Continued dental care (pregnancy hormonal changes can affect dental health; postpartum is a good time for restorative work).
• Continued vision care.
• Continued chronic disease management (diabetes, hypertension).
• Family planning and reproductive health.
• Substance use disorder treatment.

For families navigating postpartum, the extended benefit window is meaningful and should be used. After the postpartum window, families need to consider alternative coverage pathways (Pathways to Coverage if income-eligible, ACA Marketplace coverage, employer coverage).

Dual Eligible Coordination

For dual eligibles (Medicare and Medicaid), the carve-out benefits coordinate with Medicare differently for each benefit:

• Dental: Medicare does not cover routine dental services. Medicaid is primary for dental for dual eligibles. DentaQuest administers dental for dual eligibles with the same scope rules as for Medicaid-only adults (limited unless ABD or specific medical conditions apply). Some Medicare Advantage plans offer dental benefits, but original Medicare does not.
• Vision: Medicare covers limited vision (cataract surgery, ophthalmology for medical eye conditions, glaucoma screening for high-risk beneficiaries). Routine eye exams and eyeglasses are not covered by original Medicare. Medicaid wraparound applies for medically necessary vision services. Some Medicare Advantage plans offer routine vision benefits.
• NEMT: Medicare does not cover routine NEMT. Medicaid is primary for NEMT for dual eligibles. Modivcare administers NEMT for dual eligibles in QMB+, SLMB+, and full dual eligible categories.
• Pharmacy: Medicare Part D is primary for outpatient pharmacy for dual eligibles. Medicaid's role is limited to wraparound for certain Part D-excluded drugs and for QMB+ wraparound of Part D copays in some cases. The Low Income Subsidy (LIS) Extra Help program is essential for dual eligibles' Part D coverage; full LIS is available to beneficiaries up to the current Inflation Reduction Act-expanded FPL threshold (consult the Medicare Extra Help page for the current threshold).

Worked Examples

Eleanor, 78, Macon: NEMT to Dialysis

Eleanor is a 78-year-old in Macon with end-stage renal disease receiving hemodialysis three times per week at a Bibb County dialysis center. She qualifies for Aged Blind Disabled Medicaid as a dual eligible. Her standing dialysis schedule is on file with Modivcare, so she does not need to reserve each trip; Modivcare maintains her recurring schedule. On a Tuesday morning between dialysis sessions, the dialysis center adds an extra session because Eleanor's labs are concerning. Eleanor calls Modivcare to add the trip. Because dialysis is treated as an urgent recurring need, Modivcare can typically dispatch quickly. On a later date, her regular vehicle is significantly late, causing her to be late for treatment. Eleanor calls Modivcare ride assist. Modivcare apologizes and a different vehicle is dispatched. The dialysis center accommodates her late arrival but shortens her treatment. Eleanor files a written complaint with DCH Transportation Services Unit and copies the Georgia Long-Term Care Ombudsman in Macon. The Ombudsman tracks the complaint with DCH.

Marcus, 45, Albany: DentaQuest Emergency Dental for an Adult

Marcus is a 45-year-old in Albany on Aged Blind Disabled Medicaid. He has a painful tooth that has been bothering him for two weeks. As a non-pregnant adult, his Georgia Medicaid dental coverage is limited to emergency dental. He calls DentaQuest member services. The representative searches the DentaQuest provider directory for Dougherty County dentists accepting adult Medicaid. Marcus calls each. Two are not accepting new patients; the third can see him in three days. Marcus's visit confirms a tooth abscess. The dentist extracts the tooth and prescribes antibiotics. Both services are covered under adult emergency dental. The dentist notes that Marcus has multiple other dental issues that would benefit from treatment but are not covered under adult Medicaid (cleanings, fillings, crowns) unless specific medical necessity criteria are met. Marcus considers the local FQHC for sliding-scale follow-up care.

Jamil, 8, Columbus: EPSDT Vision and Eyeglasses

Jamil is an 8-year-old in Columbus enrolled in PeachCare for Kids. His mother notices he squints when reading and complains of headaches. She takes him to an Avesis-network optometrist (located through the Avesis directory). The optometrist conducts a comprehensive eye exam and diagnoses myopia. EPSDT covers an annual eye exam for children under 21, and eyeglasses are covered every 12 months with replacement available for loss or damage. The optometrist prescribes glasses and orders them through Avesis's lab partner. There is no out-of-pocket cost. Jamil receives his glasses within two weeks. Six months later, he breaks his glasses on the playground. EPSDT covers replacement; his mother contacts the optometrist who orders replacements through Avesis. The headaches resolve and Jamil's reading improves.

Aisha, 32, Savannah: Pregnancy Expansion for Dental

Aisha is a 32-year-old in Savannah, in the second trimester of pregnancy and enrolled in Pregnancy Medicaid. Pregnancy expands her dental benefit to comprehensive coverage during pregnancy and through the 12-month postpartum extension. She has not seen a dentist in five years. She calls DentaQuest to find a Chatham County dentist accepting pregnant Medicaid patients. The first provider on the list can see her within a week. The dentist conducts a comprehensive exam, identifies two small cavities and early signs of gingivitis, and performs a thorough cleaning. The cavities are filled at a follow-up appointment. The dentist explains the link between periodontal health and pregnancy outcomes (preterm birth risk) and emphasizes the importance of continued dental care through pregnancy and postpartum. Aisha delivers her baby at term. Through the 12-month postpartum extension, she continues to access comprehensive dental services through DentaQuest, completing a more extensive dental care plan that includes a periodontal scaling and root planing procedure.

Diana, 75, Rural Georgia: Modivcare Cardiology Specialty Trip

Diana is a 75-year-old in rural Bulloch County with heart failure requiring cardiology follow-up every two months at the closest specialty cardiology practice, more than an hour away in Savannah. She qualifies for ABD Medicaid as a dual eligible. She calls Modivcare in advance to reserve a wheelchair-accessible vehicle (Diana uses a wheelchair for fatigue). The reservation is confirmed. On the day of the appointment, the vehicle arrives on time, transports her to Savannah, drops her off, and the driver should wait through the appointment. But during the wait, Modivcare reassigns the driver to a different trip. When Diana finishes her appointment 30 minutes later than scheduled, no vehicle is present. She calls Modivcare ride assist; a new vehicle is dispatched and arrives 90 minutes later. Diana, fatigued and weak, waits in the clinic. She files a written complaint with DCH Transportation Services Unit and contacts the Georgia Legal Services Program for advice. The complaint is reviewed by DCH and a corrective action is communicated to Modivcare. Diana also requests that her standing cardiology schedule be set up to reduce booking friction.

Tasha, 26, Atlanta: Pathways Carve-Out Scope

Tasha is a 26-year-old in Atlanta enrolled in Pathways to Coverage. She has a tooth abscess. She calls DentaQuest. The representative explains that under Pathways, dental coverage is limited to emergency dental for relief of pain and infection. Tasha is provided with three Fulton County emergency dental providers from the DentaQuest directory. She schedules an appointment for the next day. The provider performs an exam, confirms the abscess, and extracts the tooth. The extraction and associated antibiotic prescription are covered under Pathways' emergency dental benefit. The dentist explains that routine cleanings, restorations, and ongoing dental care are not covered under Pathways and recommends Tasha apply for full Medicaid if she becomes pregnant or qualifies under another category. For transportation, Tasha calls Modivcare; Pathways covers NEMT to covered services, including emergency dental. Modivcare arranges transportation. Tasha asks DentaQuest about applying for charity dental care at a community dental clinic for ongoing maintenance; the representative provides the contact information.

How to Use the Georgia Medicaid Third-Party Administrators System

Effective navigation of the TPA system requires knowing which TPA to contact for each need.

For dental, contact DentaQuest member services. Search the provider directory. Verify coverage for adult dental issues (most adult routine dental is not covered).

For vision, contact Avesis member services. Search providers in the Avesis directory. For adults, verify that the service is covered (diabetic exams, glaucoma screening, cataract-related services, medical eye conditions).

For NEMT, contact Modivcare member reservations in advance for routine trips. For active trip issues, call Modivcare ride assist. For complaints not resolved through Modivcare, contact DCH Transportation Services Unit.

For pharmacy, contact your CMO's pharmacy member services or DCH Pharmacy Services Division for fee-for-service members.

When a need crosses TPA boundaries (such as dental work requiring medical anesthesia, or NEMT to a covered service for which the destination provider is in question), the CMO or DCH Member Services can help coordinate.

Common Access Failures and What to Do

The TPA system has predictable failure modes, and Georgia families should know what to do when access breaks down.

When a provider directory lists a provider who is not actually accepting new Medicaid patients, the family should report the inaccuracy to the TPA, document the date and call attempts, and ask the TPA to update the directory and identify alternative providers. Persistent directory inaccuracy can be reported to DCH.

When a NEMT trip fails (no-show, late arrival, inappropriate vehicle), the family should use ride assist for immediate help, document the failure (date, time, vehicle number if known, driver identifier if known, impact on appointment), and escalate to DCH Transportation Services Unit if Modivcare does not resolve.

When a dental or vision authorization is denied, the family should request the denial reason in writing, ask the provider to submit additional clinical documentation, and pursue the TPA's internal appeal process. Persistent denials can be escalated to DCH and to the state fair hearing process.

When a pharmacy claim rejects at the pharmacy counter, the family should ask the pharmacist what the rejection reason is (PA required, step therapy, quantity limit, non-formulary), contact the prescriber to address the issue, and ask about the federal Medicaid emergency-supply protection when applicable.

When a service requires multiple TPAs to coordinate (dental surgery requiring CMO-administered anesthesia), the family should work with the dental provider's office, the surgical center, and the CMO to ensure all authorizations are in place before the procedure.

Appeals Across Third-Party Administrators

Appeals can be complex when multiple administrators are involved. The general framework:

For TPA-administered benefits, the first appeal is through the TPA's internal grievance and appeal process. Each TPA has a member services line that can explain the process and provide forms.

For CMO-related issues that involve TPA-administered benefits (such as a dispute over the scope of dental coverage for a CMO member), the CMO member services and grievance process is also relevant.

For state-level review, DCH oversees each TPA contract. DCH-level complaints can be filed for unresolved issues. DCH oversight units include the Transportation Services Unit, Pharmacy Services Division, Dental Bureau, and Vision Services Unit.

For fair hearings, beneficiaries have the right to a hearing before the Office of State Administrative Hearings under federal Medicaid fair-hearing regulations. The hearing request must be filed within the timeframe in the denial notice (typically 30 days). The fair hearing is conducted by an administrative law judge.

Disability Rights Georgia, the Georgia Legal Services Program, Atlanta Legal Aid, and the Georgia Long-Term Care Ombudsman can provide assistance with appeals.

Frequently Asked Questions

A few more common questions families ask:

What is a third-party administrator and how is it different from a CMO? A third-party administrator (TPA) is a contractor that administers a specific benefit (dental, vision, transportation, or pharmacy) on behalf of Medicaid. TPAs operate under contracts with DCH or with the CMOs and serve Medicaid beneficiaries directly. CMOs are care management organizations that hold full-risk capitation contracts for medical and behavioral health services. Georgia uses TPAs for dental, vision, NEMT, and pharmacy benefits.

Does Georgia Medicaid cover vision for adults? Adult vision is also limited. Covered services include diabetic eye exams, glaucoma screening, cataract surgery and post-cataract eyeglasses, vision rehabilitation, and other medically necessary eye services. Routine exams and eyeglasses for healthy adults are not covered.

How do I schedule a NEMT trip? Call Modivcare in advance for routine appointments. For urgent appointments, the advance-notice window is shorter. For dialysis (with standing schedule) and hospital discharge, same-day reservations are possible. Have your Medicaid ID, appointment details, and any mobility needs ready when calling.

What if my NEMT driver does not show up? Call Modivcare ride assist immediately. Modivcare can dispatch a different vehicle. Document the issue (date, time, impact) and file a complaint if necessary with DCH Transportation Services Unit.

What is the 12-month postpartum extension and how does it affect my benefits? Georgia adopted the 12-month postpartum Medicaid coverage extension. Pregnant Medicaid members keep all benefits including dental, vision, NEMT, and pharmacy for the full postpartum window. Pregnancy-expanded dental benefits continue through the postpartum window.

How does Pathways to Coverage affect dental, vision, and NEMT? Pathways enrollees have limited-benefit coverage. Dental is limited to emergency dental. Vision is limited to medically necessary diagnostic services. NEMT is covered for transportation to covered services. Pharmacy is covered with PDL limitations. Verify benefits with DCH Member Services or the Pathways portal.

How does Medicare interact with these benefits for dual eligibles? Medicare does not cover routine dental or NEMT. Medicaid is primary for these benefits for dual eligibles. Medicare covers limited vision (cataract surgery, ophthalmology for medical conditions); Medicaid wraps around. Outpatient pharmacy is primarily Medicare Part D for dual eligibles, with Medicaid wraparound limited.

How do I appeal a denial? Each TPA has an internal grievance and appeal process. Start with the TPA's member services. For unresolved issues, escalate to DCH. For state-level review, request a fair hearing before the Office of State Administrative Hearings within the timeframe in the denial notice.

How accurate are the provider directories? The CMS Medicaid managed care access final rule strengthened provider directory accuracy requirements, but inaccuracies persist. Always call providers to confirm they are accepting new Medicaid patients before scheduling. Report inaccuracies to the TPA and to DCH.

Does adult dental coverage change during pregnancy? Yes. Pregnant Medicaid members receive comprehensive dental services during pregnancy. Under Georgia's 12-month postpartum extension, this expanded dental coverage continues through the postpartum window after delivery.

Can I get help finding a provider? Yes. Each TPA's member services can help you locate participating providers in your area: DentaQuest 1-844-987-0628, Avesis 1-855-214-6777, Modivcare member reservations. DCH Member Services at 1-866-211-0950 can also provide assistance.

Key Contacts

This guide is for general informational purposes only and is not legal, medical, or financial advice. Georgia Medicaid carved-out benefits are administered under contracts between DCH and the third-party administrators identified above. Coverage rules, networks, and contractor relationships change periodically. For specific coverage questions, contact the relevant administrator or DCH Member Services.

Find personalized help navigating Georgia at brevy.com.