Claims

System Overview & Access

The Georgia Department of Community Health (DCH) has selected Netsmart’s Mobile Caregiver+ (MCG+) as the state’s official Electronic Visit Verification (EVV) system, designed to capture real-time service data and help reduce fraud, waste, and abuse in home care.

Netsmart’s Mobile Caregiver+ (MCG+) is available to providers at no cost. While DCH allows approved third-party EVV vendors, any associated costs must be paid by the provider. Agencies should review their options to ensure compliance with state requirements.

EVV Support & Contact Information

Netsmart EVV Support 

• Hours: Monday-Friday, 8:00 AM – 6:00 PM EST
• Phone: 1-833-483-5587
• Website: www.NetsmartConnect.com
• EVV Portal: https://evv-dashboard.mobilecaregiverplus.com
• User Guide Link: Mobile Caregiver+ Claims Console User Guide

Required Information for Support Tickets (L2/L3 Tickets)

• Agency Name
• Agency Medicaid ID
• Agency National Provider Identification (NPI) number
• Agency Employee Identification Number (EIN) or Taxpayer Identification Number
• Contact e-mail address
• Call back number

EVV Required Procedure Codes

 The following waiver programs below are subject to EVV Program requirements:

• Service Options Using Resources in a Community Environment (SOURCE-COS 930)
• Community Care Services Program (CCSP-COS 590)
• New Options Waiver (NOW-COS 680)
• Comprehensive Supports Waiver Program (COMP-COS 681)
• Independent Care Waiver Program (ICWP-COS 660)
• Georgia Pediatric Program (GAPP-COS 971)
• EVV CPT Procedure Codes T1019 (PSS), T2025 (CLS), and S9122 (home health aide)

Claim Submission Methods

All visits for EVV-related services must be submitted through the state-mandated EVV solution, Netsmart Mobile Caregiver+ or approved third-party vendor. This includes new visits, resubmissions for denied visits, and any instances where a claim needs to be voided or adjusted.

There are two ways to submit claims:

Electronically through a clearinghouse                     Via Georgia Medicaid Web Portal (GAMMIS)

         Required for EVV Services                                   Requires an L2/L3 ticket from Netsmart

General Member Eligibility Criteria

• Member Medicaid eligibility should be verified at the beginning of each month, before every visit, or claim submission. Please note that Qualified Medicare Beneficiary (QMB) and Specified Low-Income Medicare Beneficiary (SLMB1) coverage do not provide full Medicaid benefits and, as a result do not include coverage for EVV services.
• Medicaid eligibility is determined by the members’ local county Department of Family and Children Services (DFCS) office. If the member is ineligible for Medicaid benefits, the Department of Community Health will not reimburse the provider for service provided.

Prior Authorization (PA) & Units

• Case managers provide PA numbers for new members 
• Providers must monitor approved vs. used units to avoid overages (PUNT errors) 
• Contact the case manager for PA updates or issues

Claims Processing Workflow

1. Mobile Caregiver+ Users

Completed visits that are recorded through the MCG+ Provider Portal and/or Mobile Applications are automatically uploaded, processed, and transferred to the Work List.

1. Alternate EVV Vendors

• Any user using an Alternate EVV Vendor must complete the ready-to-bill process which includes exporting completed visit data and uploading these records to the
• Mobile Caregiver+ solution for claims processing.

Once service data is uploaded to the Provider Portal, the workflow is the same for all Agencies.

WARNING: Service records exported from Alternate EVV Vendors that contain invalid or missing data—such as non-ICD-10 diagnosis codes or incorrect provider IDs—will be rejected. Contact your EVV vendor for assistance in locating and correcting rejected visit data.

   2. Work List Screening (Pre-Adjudication)

• Service records in the Work List are pre-adjudicated using Payer’s rules and assigned one of two statuses.
• Matched – No errors detected, eligible for claim submission.
• Unmatched – Contains errors; must be corrected and rescreened before submission.

   3. Provider Administrator’s Actions

• Provider Administrators can review, select, and release Matched records for claim submission.
• Provider Administrators must remediate and rescreen Unmatched records until they are Matched.

   4. Claim Review and Submission

• Released service records are sent to the Payer and can be reviewed in the Claim Review.

   5. Payer Adjudication and Payment

• Payer adjudicates claim(s) and issues payment.
• Providers can check for status and remittance information in Claim Review.

After a visit has been completed, the Provider Administrator can review, adjust and electronically release the visit as a claim to the Payer via the Work List screen in the Provider Portal.

• If a Provider uses the Mobile Caregiver+ Solution, the Mobile Caregiver+ Claims Console will automatically process and transfer service records to the Work List for Claims Processing. Providers can use the Visits list to troubleshoot missing service records. If successfully transferred to the Work List, the system will display “SUCCESS” in the Visits to Claims status field in the Visits option of the Main Menu.

• If a Provider is using an Alternate EVV System, Providers must complete the ready-to-bill process (send visit data to their Mobile Caregiver+ Provider Portals for claims processing) before the Mobile Caregiver+ Claims Console will process and transfer billable service records to the Work List.

***Service records that are successfully processed for completed visits will be transferred to the Work List, where they will be screened using Payer defined pre-adjudication rules. ***

Three potential Work List statuses:

1. New – Service records that are initially transferred to the Work List or service records that were just edited or updated.
2. Matched – Service records that have been screened and are following the defined Payer rules; Matched service records do not have reported errors and can be released for remittance. Only Matched service records can be released for claims submission.
3. Unmatched – Service records that have been screened and are not in line with the defined Payer rules; Unmatched service records have reported errors that must be remediated and rescreened to change the status to Matched.

In the Work List, a Provider Administrator can click on the service record to expand and view the visit details. Any field in the Work List with the pencil icon  can be edited or adjusted to reflect billable visit data if the actual visit data is inaccurate. All fields labeled as ‘Actual,’ is visit data recorded by a mobile device and cannot be adjusted. Any adjusted ‘Billable’ values will always override ‘Actual’ values and will be sent for claims submission.

Provider Administrators are required to select Reason Codes to provide explanations for changing rendered service data.

Only Matched service records can be released for claims submission. For all Unmatched service records, Providers MUST fix all reported errors to change the status to Matched before releasing for claims submission. Follow the steps below for Matched and Unmatched service records.

1. For service records in the status of ‘Matched’:

a. Select the visit checkbox.

b. Select ‘Release’.

c. The visit will be released to the Payer and the status can be reviewed in

Claim Review. The status will change to ‘Released’.

2. For service records in the status of ‘Unmatched’:

a. Click on the Unmatched service record to open it.

b. Scroll to the bottom of the service record, to the Edits and Errors

Report error.

c. Remediate and clear all the reported errors. Refer to How to Clear

Reported Errors in the Work List section of this document.

d. Once all reported errors have been resolved, select the visit checkbox.

e. Select ‘Rematch’. Rematching a service record will screen the service

record against the Payer’s set rules again. Once rematched, the visit

Status should reflect ‘Matched’ and can be released to claims

submission.

Claim status after being released from the Work List can be monitored on the Claim Review screen. *Voids and Adjustments to claims can also be done in Claim Review. *

Service Records displayed in Claim Review will have one of nine statuses:

1. Released – Billable service records that have been released from the Work List but have not yet been submitted to the Payer.
2. Submitted – Billable service records that have been submitted to the Payer.
3. Accepted – Billable services that have been accepted by the Payer, which are then considered as claims to be reviewed for adjudication. Claims that are accepted by the Payers are assigned Internal Control Numbers (ICN) to be used for identification.
4. Rejected – Billable services that have technical errors, such as incorrect or missing data will be labeled as “Rejected;” Rejected service records are returned to the Mobile Caregiver+ Work List for remediation.
5. Denied – Claims that the Payer accepted, reviewed, and adjudicated to deny (refuse) payment for. Claims may be denied for untimely submission, duplicate claim submission, etc.
6. Paid – Claims that the Payer accepted, reviewed, and adjudicated to remit the full amount.
7. Paid Partial – Claims that the payer accepted, reviewed, and adjudicated to remit partial payment for. Providers may choose to adjust partially paid claims.
8. Adjusted – Paid or Partially Paid claims that a Provider has edited (made changes to_ and resubmitted for adjudication).
9. Voided – Paid or Partially Paid claims for which a Provider has voided (reversed) payment

 Key EVV Workflow Notes

• Completed visits move to the Worklist for review before submission 
• In the Worklist, providers can review each visit, whether matched or unmatched, before manually releasing visits for adjudication
• Unmatched visits must be corrected prior to release 
• Suspended (“PENDED”) visits require follow-up and can not be modified. Contact Gainwell (GAMMIS) for assistance.

• Denied visits must be recreated as new claims. Check GAMMIS Remittance Advice for details. 

  Note: For detailed instructions on Unmatched Error Codes Reasons or Releasing Matched Services Records for Claim Submission, please refer to Sections 7.6 through 7.16 of the Claims Console User Guide. Also, instructions on resubmitting denied claims, please refer to Section 8.4 of the Claims Console User Guide under “Locating and Remediating Denied Claims.”

Voiding & Adjusting Claims

• Only paid or partially paid claims can be adjusted/voided 
• Adjustments must follow Medicaid timely filing rules (90 days from paid date) 
• Can not resubmit voided claim until next billing cycle
• EVV-released claims should not be adjusted in GAMMIS unless approved

 Managing Authorized Units Through EVV

Effectively managing APPROVED vs. USED units linked to a recipient’s prior authorizations is essential for: 

• Ensuring accurate reimbursement. 
• Preventing overpayments. 
• Reducing the risk of PUNTs (unit overages) in the EVV solution. 

Providers can track and manage the number of units linked to a prior authorization by: 

• Reviewing the authorization details in the Prior Authorization menu. 
• Using the Search Visit to Claim Reconciliation function in the Visit menu.

Please contact the Case Manager for any updates as it pertains to the Prior Authorization units. Once the update is complete, you can verify by reviewing the PA details prior to submitting your claim.

Rounding Rules

The State EVV system, Netsmart, follows Medicaid rounding standards set by the Centers for Medicare & Medicaid Services (CMS). Service times of up to 7 minutes are rounded down, while 8 minutes or more are rounded up to the nearest 15-minute increment. For Personal Support Services (PSS) billed on an hourly basis, service times under 30 minutes are rounded down to the previous whole hour, and 30 minutes or more are rounded up to the next whole hour.

15-Minute Increment Billing:

• 1 unit: 8–22 minutes 
• 2 units: 23–37 minutes 
• 3 units: 38–52 minutes 
• 4 units: 53–67 minutes 
• 5 units: 68–82 minutes 
• 6 units: 83–97 minutes 
• 7 units: 98–112 minutes 
• 8 units: 113–127 minutes 

One-Hour Unit Billing:

• 1 unit: 30–60 minutes 

Note: For more details, please refer to Rounding Rules Section 911 in the EDWP–CCSP and SOURCE General Services Policy Manual. Services that are not billed in 15-minute increments must instead follow the “Reimbursement Rates for CCSP and SOURCE” table provided in the Appendix.

 Common Claim Denial Codes

• 512: Timely filing exceeded
• 535: Adjustment exceeds the timely filing limit 
• 3000: Prior authorization (PA) units are exhausted or only partially available 
• 3011: Date of service falls outside PA/precertification effective dates 
• 4021: No coverage for the billed procedure 
• 5035, 5037, 5042: Exact duplicate claim 
• 5038, 5043: Potential duplicate claim 
• 5044: Possible conflict with another waiver program 
• 5115: Service not permitted during a hospital stay

EVV Claim Filing Deadlines

Weekly Deadline

• Claims must be submitted by Thursday at 11:59 PM for Friday payment cycles 
• Claims submitted after Thursday will have their payment delayed by one week.
• Provider must have an L2/L3 Ticket from Netsmart to bill claims through GAMMIS.

Timely Filing 

Claim Submission

• Initial claim: 6 months from the month of service
• One Year (365 days) Claim Submission: All claim submissions and adjustments to denied claims are to be completed according to policy by 365 days.

Claim Resubmissions

• Denied claims: within three months of the denial month

Claim Adjustments

• Claim adjustments: within three months of the payment month

Remittance Advice (RA)

Remittance Advice is issued weekly when there are claims activity during that cycle. It typically includes:

• Banner messages 
• Claim activity and status details 
• Financial transactions (expenditures and accounts receivable) 
• Explanation of Benefits (EOB) descriptions 
• Summary page 

To access the RA in the Georgia Medicaid Management Information System (GAMMIS):

• Navigate to Reports, then Financial Reports 
• Select Remittance Advice from the dropdown 
• Enter the desired date range and click Search