Georgia - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-15

In Georgia, Medicaid Case Management services—encompassing assessment, person-centered service planning, referral, and monitoring—are delivered through Targeted Case Management (TCM) and specific Home and Community-Based Services (HCBS) waivers such as the Elderly and Disabled Waiver Program (EDWP), NOW, and COMP. The service ensures that individuals receive coordinated, conflict-free care that integrates medical, behavioral, and social supports.

The single biggest structural barrier to entry is that Georgia does not utilize an open-market enrollment model for standalone case management agencies. Depending on the target population, providers are structurally blocked by either the requirement to subcontract exclusively under a regional Area Agency on Aging (for CCSP) or the requirement to pass the Georgia Collaborative ASO's Letter of Intent (LOI) process during strictly defined, closed open-enrollment windows (for DBHDD's NOW/COMP waivers).

1. Service Definition and Scope

Case Management in Georgia is defined as services that assist Medicaid members in gaining access to needed medical, social, educational, and other services. Core activities include comprehensive assessment, development of a person-centered service plan (PCSP), referral to qualified providers, and ongoing monitoring of the participant's health and welfare.

Federal regulations strictly enforce conflict-free case management. This means the agency or individual providing case management cannot also be the direct provider of the participant's home care or waiver services, ensuring objective oversight of the care plan.

• Target Populations: Elderly and physically disabled adults (EDWP/CCSP/SOURCE), individuals with intellectual/developmental disabilities (NOW/COMP), and individuals with severe behavioral health needs.
• Core Components: Comprehensive needs assessment, person-centered service plan development, service referral, and continuous monitoring.
• Conflict-Free Mandate: Case managers must be entirely independent of the participant's direct HCBS service providers to prevent self-referral and bias.
• Participant Direction Support: In NOW and COMP waivers, case managers assist participants who self-direct their care, ensuring the Representative for Participant Directed Services is not paid staff.
• Service Exclusions: Time spent on agency administration, staff supervision, or direct service delivery cannot be billed as case management.

2. Regulatory and Oversight Agencies

Jurisdiction over case management in Georgia is divided among several state agencies depending on the target population. The Georgia Department of Community Health (DCH) holds ultimate authority over Medicaid and operates the billing portal, but programmatic oversight is delegated.

For intellectual, developmental, and behavioral health populations, the Department of Behavioral Health and Developmental Disabilities (DBHDD) acts as the primary regulator. For aging populations, the Division of Aging Services (DAS) manages the network.

• Department of Community Health (DCH): The state Medicaid agency that operates GAMMIS, processes provider enrollment, and oversees overarching HCBS waiver compliance.
• Department of Behavioral Health and Developmental Disabilities (DBHDD): Oversees the NOW and COMP waivers and behavioral health TCM, dictating provider network access and certification.
• Division of Aging Services (DAS): Manages the Area Agencies on Aging (AAAs), which hold the statutory responsibility for CCSP case management.
• Georgia Collaborative ASO: The administrative entity contracted by DBHDD to manage new provider enrollment forums, process Letters of Intent (LOIs), and conduct initial application reviews.
• Gainwell Technologies: The fiscal agent contracted by DCH to process GAMMIS enrollment applications and manage Medicaid claims.

3. Gatekeeping Prerequisites: Who Can Even Apply

This is the most restrictive phase of becoming a provider in Georgia. You cannot simply submit a Medicaid application to DCH for case management; access is heavily gated by procurement and network management strategies specific to each waiver.

If an applicant attempts to bypass these structural preconditions and applies directly through GAMMIS, the application will be immediately denied. Furthermore, DCH enforces a strict one-year moratorium on re-applying if an application is denied.

• DBHDD Open Enrollment Windows: Applications for I/DD or Behavioral Health case management are only accepted during specific, published enrollment periods; the network is closed at all other times.
• Mandatory Provider Forum: Prospective DBHDD providers must register for and attend a New Provider Enrollment Forum hosted by the Georgia Collaborative ASO before taking any other steps.
• Letter of Intent (LOI): DBHDD requires submission and approval of an LOI during an open window before an agency is invited to submit a full application.
• AAA Subcontracting (CCSP): For the Community Care Services Program, case management is structurally restricted to regional Area Agencies on Aging (AAAs); independent agencies must secure a contract with the AAA rather than applying directly to DCH.
• One-Year Moratorium: If a DCH application is denied (even after DBHDD approval), the applicant must wait one full year before restarting the process at Phase 1 in a subsequent enrollment period.

4. Licensure and Certification Requirements

Georgia does not issue a standalone "Case Management Agency" facility license through the DCH Healthcare Facility Regulation (HFR) division. Unlike personal care agencies that require a Private Home Care Provider (PHCP) license, case management relies on programmatic certification.

Instead of a facility license, agencies achieve the legal authority to operate through DBHDD certification (for NOW/COMP/BH) or DAS designation (for CCSP). This programmatic approval serves as the prerequisite for Medicaid enrollment.

• Facility License Exemption: No DCH HFR Private Home Care Provider (PHCP) license is required strictly for the provision of case management services.
• DBHDD Certification: Acts as the functional equivalent of licensure for NOW/COMP and behavioral health providers, requiring a rigorous site visit by the Regional Field Office.
• National Accreditation: DBHDD frequently requires behavioral health TCM providers to hold active national accreditation from CARF, The Joint Commission (TJC), COA, or CQL.
• Local Business License: A city or county business license is required to verify the physical operating location of the agency in Georgia.
• Secretary of State Registration: The operating entity must be registered and in good standing with the Georgia Secretary of State.

5. Medicaid Provider Enrollment

Once programmatic approval (such as a DBHDD invitation to apply) is secured, providers must enroll in Medicaid through the Georgia Medicaid Management Information System (GAMMIS).

The enrollment process is entirely digital and requires exact matching of corporate, tax, and credentialing data. Discrepancies between the application and state or federal databases will trigger immediate rejection.

• GAMMIS Portal: All Medicaid enrollment applications must be submitted via the Enrollment Wizard at mmis.georgia.gov.
• NPI Requirements: Agencies must obtain a Type 2 (Organizational) NPI from NPPES, and the provider taxonomy code must exactly match the specialty designation on the GAMMIS application.
• Application Tracking Number (ATN): GAMMIS automatically generates an ATN upon submission; this number is required for all status checks and correspondence with Gainwell.
• Ownership Disclosure: Applicants must complete the 42 CFR 455.104 disclosure, listing every individual or entity with a 5 percent or more direct or indirect ownership interest.
• Application Fee: Agencies are subject to the ACA institutional provider application fee (approximately $731) unless they provide proof of prior payment to Medicare or another state's Medicaid program.

6. Staffing, Training and Background Checks

Case managers in Georgia must meet strict educational and professional criteria to ensure they are qualified to assess complex medical and social needs. Requirements vary slightly by target population but generally mandate higher education.

Agencies must maintain a master credentialing file for all staff. State surveyors and GAMMIS auditors rigorously check these files during site visits and revalidation.

• Educational Minimums: Staff generally must hold a Bachelor's or Master's degree in social work, psychology, nursing, education, or public health.
• Professional Licensure: Depending on the acuity of the population, roles may require active Georgia licensure as an RN, LCSW, LPC, or LMFT.
• Background Checks: Mandatory fingerprint-based criminal background checks must be processed through the Georgia Applicant Processing Service (GAPS).
• DBHDD Orientation: Newly approved DBHDD providers must complete a mandatory New Provider Orientation before they can begin billing.
• Credential Verification: License names, numbers, and expiration dates must exactly match the records held by the Georgia Composite Medical Board or relevant licensing board.

7. Documentation, Policies and Records

Because of a long history of federal enforcement regarding Targeted Case Management, documentation requirements in Georgia are exacting. Paperwork must clearly justify every billed unit.

Person-centered service plans (PCSPs) are the cornerstone of HCBS case management. These plans must be updated at least annually, or whenever the participant's condition or circumstances change significantly.

• Contact Logs: Documentation must support billed time by detailing the date, duration, nature of each contact, specific activities performed, and outcomes.
• PCSP Requirements: Plans must document the participant's goals, caregiver roles, back-up plans, and evidence that the participant was offered a choice of conflict-free providers.
• Non-Billable Time Policies: Agency manuals must clearly define and exclude time spent on agency administration or staff supervision from TCM billing.
• Form 5382: Agencies managing EDWP cases must utilize official state forms, such as the Notice of Denial, Termination, or Reduction in Service (Form 5382).
• Record Retention: Clinical and financial records must be retained in accordance with DCH policies, typically for a minimum of six years.

8. Billing, Rates and Claims

All case management claims are submitted through GAMMIS. The billing structure depends heavily on the specific waiver or TCM population being served.

While personal care services in Georgia require Electronic Visit Verification (EVV) through NetSmart/Tellus, professional case management services are generally exempt from EVV clock-ins, though strict prior authorization rules apply.

• Billing System: All claims are processed through the Georgia Medicaid Management Information System (GAMMIS) at mmis.georgia.gov.
• Unit Structure: TCM is typically billed in short units (e.g., 15-minute increments), while some intensive programs like SOURCE utilize monthly bundled rates.
• Prior Authorization: Services cannot be billed unless they are linked to an active prior authorization in GAMMIS; billing without authorization results in automatic denial.
• EVV Exemption: Case management is generally exempt from the NetSmart/Tellus EVV requirements that apply to direct personal care services.
• Claim Timeliness: Claims must typically be submitted within 6 months of the date of service to avoid timely filing denials.

9. Approval Sequence and Timeline

The end-to-end process for becoming an approved case management provider is lengthy, primarily due to the phased DBHDD and Georgia Collaborative ASO approach.

Providers should expect a minimum of 6 to 12 months from attending the initial forum to receiving final GAMMIS approval and a Medicaid ID.

• Phase 1 (1-2 months): Register for and attend the Georgia Collaborative ASO forum, then submit the Letter of Intent (LOI) during an open enrollment window.
• Phase 2 (2-4 months): Upon LOI approval, submit the full DBHDD application and undergo a site visit by the Regional Field Office.
• Phase 3 (1-2 months): Receive official DBHDD approval and submit the DCH/GAMMIS enrollment application.
• Phase 4 (1-3 months): Gainwell processes the GAMMIS application, issues the Medicaid Provider ID, and the agency completes mandatory orientation.

10. Common Denials and Survey Findings

Applications are frequently rejected at the GAMMIS stage for administrative mismatches or for failing to follow the strict LOI sequence mandated by DBHDD.

Post-enrollment, state audits focus heavily on documentation gaps and violations of the conflict-free case management mandate.

• Out-of-Sequence Applications: Submitting a GAMMIS application before receiving official DBHDD approval or an AAA contract results in immediate denial and a one-year lockout.
• Credential Mismatches: Application rejections occur when license names, numbers, or expiration dates on the GAMMIS application do not exactly match Georgia state records.
• TIN/IRS Mismatches: W-9 Tax Identification Numbers failing federal database verification will halt the enrollment process.
• Billing for Administration: Audits frequently penalize agencies for billing TCM units for supervisory tasks, travel time, or administrative overhead.
• Conflict of Interest Violations: Severe findings are issued when case managers are found to be affiliated with or steering participants toward specific direct service providers.

11. Key Contacts and Resources

Keep these official state portals and contacts bookmarked for the enrollment process. Because open enrollment windows change, always rely on official state websites rather than third-party summaries.

When contacting Gainwell regarding a pending application, always have your Application Tracking Number (ATN) ready.

• GAMMIS Portal: mmis.georgia.gov for Medicaid provider enrollment, ATN tracking, and claims submission.
• Georgia Collaborative ASO: georgiacollaborative.com for DBHDD provider enrollment forums, LOI forms, and application phases.
• DBHDD Provider Enrollment: dbhdd.georgia.gov for specific Intellectual/Developmental Disability and Behavioral Health program requirements.
• DCH Provider Services: Gainwell Technologies help desk at 1-800-766-4656 for GAMMIS enrollment support.
• Division of Aging Services (DAS): aging.georgia.gov for the Area Agency on Aging (AAA) directory and CCSP information.

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