Georgia medical billing and payer rules

Timely filing in Georgia

Georgia Chapter 20E and the federal No Surprises Act

Georgia regulates out-of-network payment for fully insured plans through the Surprise Billing Consumer Protection Act. The federal Act supplements it and governs self-funded plans.

Major payers

How does Georgia Medicaid work for billing?

Georgia runs Medicaid and PeachCare for Kids through the Georgia Department of Community Health (DCH), Division of Medical Assistance Plans. Its provider manual, Part I Policies and Procedures for Medicaid/PeachCare for Kids (version dated July 1, 2026), sets the rules below. Two payment paths exist: fee-for-service claims that go through the state's web portal, and claims for members enrolled in a managed care plan.

The fee-for-service portal is GAMMIS, the Georgia Medicaid Management Information System at www.mmis.georgia.gov. The portal's own home page describes it as the primary web portal for Medicaid, PeachCare for Kids and related waiver programs, and names Gainwell Technologies as the fiscal agent for DCH.

Which managed care plans does DCH use?

DCH's network adequacy page states that the department contracts with three care management organizations (CMOs): Amerigroup, CareSource and Peach State Health Plan. All three serve members across the state under the Georgia Families contract, and Georgia Families is the name of the managed care program.

A member in one of those plans is billed to the plan, not to GAMMIS fee-for-service. Each plan has its own manual and claim edits, so check the plan assigned on the date of service. The general mechanics are in our Medicaid billing guide.

What local rule catches billing teams most often?

Revalidation. Part I section 105.15 says the Division revalidates the enrollment of all providers, whatever their type, at least every three years, and suspends or terminates a provider who fails to submit a re-credentialing application. It adds that the Department suspends a provider who does not submit one within 60 days of the re-credentialing notice.

The GAMMIS home page carried an alert posted May 25, 2026. Providers who have not revalidated are suspended effective July 1, 2026, claims for later dates of service are not paid, and retroactive enrollment is not permitted. A provider who does not revalidate within 30 days of a suspension notice is terminated, with appeal rights.

What is the Georgia Medicaid timely filing limit?

For fee-for-service claims, Georgia Medicaid requires the claim to be received within six months after the month in which the service was rendered. Part I section 203.1.3 says failure to file so that the claim is received within six (6) months after that month, or failure to get a required prior approval, results in denial. The clock runs from the month of service, not the exact date.

That is shorter than the federal outer limit. Under 42 CFR 447.45(d)(1) a Medicaid agency must require providers to submit all claims no later than 12 months from the date of service. Georgia's manual sets six months for the standard claim and uses 12 months only for named exceptions.

What about the managed care plans?

The manual governs fee-for-service claims. This page cites no source for the filing window of Amerigroup, CareSource or Peach State Health Plan, so it does not state one. Read the timely filing section of each plan's current provider manual and put the shortest window in your tracker. Do not assume it matches the state's six months.

Who is the Medicare contractor for Georgia?

Palmetto GBA, LLC is the Medicare Part A and Part B administrative contractor for Georgia, in Jurisdiction J. The CMS list of contractors by state shows Alabama, Georgia and Tennessee together under Palmetto GBA, and the three states are often called JJ. Your MAC processes fee-for-service claims.

The timely filing limit is one calendar year. Under 42 CFR 424.44(a)(1), the claim must be filed no later than the close of the period ending 1 calendar year after the date of service. The detail is on our Medicare billing page.

After a denial, a redetermination must be filed within 120 calendar days of receiving the initial determination (42 CFR 405.942), and a reconsideration within 180 calendar days of receiving the redetermination notice (42 CFR 405.962).

Does Georgia have a prompt pay law?

Yes. The Office of the Commissioner of Insurance (OCI) states that O.C.G.A. 33-24-59.5 and 33-24-59.14 require the prompt payment of claims by insurers offering and administrators servicing health benefit plans. OCI Bulletin 21-EX-2, dated January 27, 2021, also requires those entities to send claims data every quarter. Filing dates are May 15, August 15, November 15 and February 15 for the preceding quarter.

This page does not quote 33-24-59.5, so the general clean claim deadline and late interest rate are not stated here. Pull the section from the current Official Code of Georgia Annotated before you cite it.

What we did read is the deadline for amounts owed under the surprise billing chapter. HB 295 (2023) revised O.C.G.A. 33-6-34(15) so that failing to pay the provider or facility directly within 15 working days for electronic claims or 30 calendar days for paper claims, for money due under 33-20E-4 or 33-20E-5, is an unfair claims settlement practice. Under HB 888 itself, those payments must follow 33-24-59.14.

Does Georgia have its own surprise billing law?

Yes. Georgia's Surprise Billing Consumer Protection Act is Chapter 20E of Title 33 of the Official Code of Georgia Annotated. OCI's rule 120-2-106 implements it, and HB 295 (2023) changed several sections, including the arbitration filing window. It covers state-regulated plans, and it sits next to the federal No Surprises Act, which still governs self-funded ERISA plans.

OCI's rule applies only to healthcare plans and state healthcare plans, and plans under the exclusive jurisdiction of federal law are not eligible for review. State plans such as the state employees' plan and the Regents Health Plan are included, as are stand-alone dental and vision plans. Medicare, workers' compensation, limited benefit policies and air ambulance insurance are outside the definition.

Which services are covered?

• Emergency services from any out-of-network provider or facility. The insurer must pay without prior authorization and without retrospective denial of medically necessary care (rule 120-2-106-.05).
• Non-emergency services that produce a surprise bill: charges from an out-of-network provider at an in-network facility (rules .03 and .06).
• Ground ambulance is handled separately. The rule says nothing in it reduces a covered person's financial responsibility for ground ambulance transportation (rule .02).

How much must the insurer pay?

For emergency and covered non-emergency surprise bills, the insurer pays the out-of-network provider directly the greater of three amounts: the verifiable median contracted amount calculated by a vendor the Commissioner chooses, the most recent amount the insurer and provider agreed while the provider was in network, or a higher amount the insurer considers appropriate. The patient owes only the plan's cost sharing.

Each insurer payment must come with a notice saying whether the plan is under the exclusive jurisdiction of ERISA. That notice is your first check on the dispute path.

HB 888 as passed adds two protections. A plan may not deny or restrict covered benefits from an in-network provider because the patient got care from a nonparticipating provider that led to a balance bill (33-20E-6). A patient who chose out-of-network non-emergency care falls outside the surprise bill rules only after giving written and oral consent in advance and receiving a charge estimate (33-20E-7).

How does it fit with the federal No Surprises Act?

CMS says the No Surprises Act supplements state surprise billing laws and does not replace them. A state law that gives at least the same protection generally applies, but a state cannot enforce it against a self-insured plan that has not opted in. No official statement says whether CMS treats Georgia's process as the state method for setting the out-of-network rate, so confirm the pathway claim by claim from the insurer's ERISA notice, or call the No Surprises Help Desk at 1-800-985-3059. Our state surprise billing laws guide compares states.

How does Georgia arbitration work for an out-of-network underpayment?

A provider that thinks an insurer's payment was too low can ask the Commissioner for arbitration. Under rule 120-2-106-.10, the request must be submitted within 60 days of receiving payment, with a copy to the insurer, to the Administrative Procedure Division of the Office of Insurance and Safety Fire Commissioner. HB 295 moved the statutory window from 30 to 60 days and requires insurers to mark the payment on the first page of the remittance.

An out-of-network facility can use the process only for emergency payments under rule .05. A provider can use it for emergency and covered non-emergency payments.

1. Confirm the plan is state-regulated. A claim against a plan under the exclusive jurisdiction of ERISA is dismissed.
2. File with the Administrative Procedure Division within 60 days of receiving payment, copy the insurer, and explain why arbitration is needed.
3. The insurer has 60 days from receipt to send OCI data showing its payment complied. If it does not, OCI may assess penalties or declare a default judgment.
4. The parties have 60 days from OCI's receipt to negotiate. Without a reported settlement or extension, OCI refers the dispute to a resolution organization within five days.
5. The parties have five days to agree on an arbitrator, or the resolution organization picks one.
6. Each side submits one proposed payment amount. The arbitrator picks one, cannot modify it, and decides in writing within 60 days of referral. The decision is binding and not appealable through the courts.

OCI may dismiss a request that is late or does not explain why arbitration is needed. A provider that fails to answer OCI's data request within 60 days can be fined up to $2,000 per violation, or $5,000 where it knew or should have known. A resolution organization under contract with OCI decides disputes.

HB 888 as passed also bars both sides from suing in court over the same claim once a request is filed (33-20E-18). The side whose offer loses pays the decision amount and the arbitrator and resolution organization fees within 15 days (33-20E-16). A nonparticipating provider may not report a patient to a credit agency over a surprise bill for amounts beyond in-network cost sharing (33-20E-22). The bill says it takes effect January 1, 2021, while the rule's own text says January 1, 2020, so check the date for a 2020 claim. For the federal alternative, see out-of-network billing and IDR.

Which payers matter in Georgia?

The payers we can show operate in Georgia from official sources are the three Medicaid CMOs, Palmetto GBA for Medicare fee-for-service, and the state's own plans. This page cites no OCI market share report, so we do not name commercial carriers or give market share here.

How do you appeal a denied Georgia Medicaid claim?

Start with an initial review in GAMMIS. Part I section 502.1 says a rendering provider may ask for an initial review of a claim payment denial by submitting a DMA-520 Provider Inquiry form through the web portal, and that DCH and Gainwell have not accepted paper or faxed DMA-520 forms since October 1, 2014. The request must be made within 30 days of the date of the denial.

How we handle billing in Georgia

For Georgia we keep two clocks per claim. One is the month-of-service clock that decides whether Georgia Medicaid or the Georgia Families plan will still take the claim. The other starts on the day an out-of-network payment is received, because the 60-day arbitration window under OCI rule 120-2-106-.10 runs from that payment.

On every out-of-network payment we read the ERISA notice first, then decide between OCI arbitration and federal IDR. Claims go out within 24 hours of charge entry and denials are worked within 48 hours, so the usual problem is a missing revalidation or a wrong plan. To have a Georgia hospital or ER group reviewed, book a call. See also our hospital and facility billing service.