Georgia Medicaid

Alliant | GMCF has continuously served the Georgia Medicaid program since 1972 through professional health care services, including Utilization Management, Program Integrity, and Quality Management & Improvement services.

Utilization Management services ensure appropriate allocation of resources through evaluating the medical necessity and appropriateness of health services. This includes prior authorization and concurrent & retrospective reviews; utilization trend analysis; and medical policy consultation. Program Integrity services ensure program compliance and appropriate payments, including fraud & abuse detection analysis; desk and onsite medical record reviews; onsite program compliance audits, surveillance and utilization review studies and record reviews; and provider education to improve compliance. Quality Management & Improvement services focus on improving the care and health of the Medicaid population. This includes quality improvement projects; program evaluation and consultation; HEDIS data collection and analysis; and provider education.

Medicaid Medical Management Services Contract

As the current Georgia Medicaid Medical Management Services vendor for the Georgia Department of Community Health (DCH-Georgia Medicaid Department), Alliant | GMCF performs more than 500,000 medical reviews annually. Alliant ASO conducts the following types of utilization management medical reviews:

• Inpatient Hospital Reviews
• Outpatient Reviews, including mental health and therapy (PT,OT and ST) services
• Durable Medical Equipment/Orthotics/Prosthetics/Medical Supplies
• Psychiatric Admissions
• Dental
• Hearing/Visions
• Emergency Ambulance/Transportation
• Physician Office Visits
• Oral/Maxillofacial Surgery
• Early Periodic Screening, Diagnosis, and Treatment (EPSDT)
• Swingbed/Intermediate Care Facility for the Mentally Retarded (ICF-MR)
• Pre-Admission Screening and Resident Review (PASRR) for Nursing Home Admissions
• Emergency Review of Undocumented Aliens
• Radiology Services
• Injectable Medications
• Home and Community Based Waiver Program Reviews
• Children’s Intervention Services
• Retrospective/Concurrent Reviews
• Outlier Reviews

In addition to these reviews, Alliant | GMCF provides suspended claims/pre-payment review, Utilization Analysis, Medical Policy Consultation, Focused Studies, Outcome Reports, Proposals to Improve Health System, Provider Education, and of Nurse Aide Training Program and Registry Management.

Utilization and Compliance Review

Alliant | GMCF performs utilization and compliance review services for specific portions of the Medicaid population to support the Program Integrity Unit’s surveillance program and ensure compliance with the Improper Payments Information Act of 2002. We audit the acquisition of health care services by conducting onsite provider reviews statewide, validating compliance with applicable healthcare policies and determining instances of incorrect billing and/or medically unnecessary or inappropriate services and report findings of fraud and abuse to the Director of Program Integrity. The utilization review process for providers includes analysis of selected claims data, medical records, departmental reports, films, x-rays and other documentation needed to assess services billed to Medicaid. We determine estimates of recoverable amounts by reviewing coding and billing patterns and identifying payment errors.

To learn more about Georgia Medicaid please visit the Georgia MMIS Web Portal and the Department of Community Health.