Georgia's CareSource Measures ABA Progress in Standardized Assessments, Not Notes

Health Net gives you six months. CareSource gives you twelve — and then asks for something a progress note cannot supply.

CareSource's Georgia Medicaid policy MCD-MM-0212, effective July 1, 2026, lists the conditions under which ABA should be titrated or discontinued. One of them:

“Member behavior does not demonstrate meaningful progress for two successive 6-month authorization periods as demonstrated via standardized assessments.”

Two things are happening in that sentence. The clock is twelve months, not six. And the proof is a standardized assessment — an instrument with a score, administered and re-administered — not a clinician's account of how the year went.

Why the evidence standard matters more than the clock

A six-month test you can argue with narrative. A twelve-month test measured by standardized assessment you cannot: either you administered the instrument at both ends of the period or you did not, and if you did not, you have no admissible evidence of progress at the moment it is asked for.

The policy separates the assessment from the diagnosis explicitly, defining a behavioral assessment as “separate from the initial diagnostic evaluation, the administration of an industry-standard assessment tool for skill acquisition and/or behavior reduction required to substantiate future treatment services.” Substantiate future treatment is the operative phrase. The assessment is not a clinical formality; it is what buys the next authorization.

The rest of the policy, in the order it will reach you

• Authorized hours: “typically 10–30 hours” per week, and must be “commensurate with skill deficit or behavioral excesses as identified in the BA.” Not a hard cap, but a stated range with the assessment as its justification.
• Comprehensive behavioral assessments “are not to exceed 8 hours every 6 months” unless additional justification is provided. If your standard intake assessment runs longer, it needs a written reason every time.
• An independent practitioner must conduct the assessment and develop the plan of care before services are provided. Independent, and before.
• “Active parent/caregiver participation and involvement is required.” Stated as a requirement of the treatment authorization, not an aspiration.
• The 28-day trap. “Certain services may be allocated into 28-day periods and not eligible for carryover, even if an authorization is approved for 6 months.” A six-month authorization does not mean a six-month pool. Unused units inside a 28-day window are gone.

And how it will be checked

The policy names its own enforcement: compliance “may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review.” It adds, separately: “CareSource reserves the right to request supervision documentation.”

Prepay review is the one to notice. Post-payment recovery takes money back; prepay review stops it arriving.

The limits

This is one managed care organization's medical policy, not Georgia Department of Community Health policy — CareSource states it follows DCH and applicable state and federal law, and the policy repeatedly defers to the ASD Services Manual (sections 802 and 803) for the actual documentation requirements. A medical policy statement does not by itself guarantee or deny an authorization. The discontinuation list is explicitly “not an all-inclusive list,” which cuts both ways: other grounds exist, and the twelve-month standard is not the only route to titration. The policy was first issued in November 2017 and this is a revision, so not every provision here is new on July 1.

What you must know or do

• Check whether you actually administer a standardized assessment at both ends of every authorization period. Not an intake assessment and a progress summary — the same instrument, twice, scored. If you do not, the twelve-month test has no evidence to weigh in your favour when it is applied.
• Name the instrument in the plan of care. The policy requires an “industry-standard assessment tool.” Which one, administered when, by whom, is the record that survives a prepay review.
• Time your assessment hours. Eight hours per six months is the ceiling before justification. Providers running comprehensive assessments as a matter of course will hit it and need the written reason ready in advance, not after a denial.
• Find out which of your services sit in 28-day allocations. Then check whether your scheduling assumes a six-month pool. Any service delivered late in a period against units that expired 28 days earlier is unpaid work you have already done.
• Multi-state operators: that is now three different discontinuation clocks — six months at Health Net for Medi-Cal, twelve months across two authorization periods at CareSource in Georgia — measured by different evidence. A single continuation-documentation template will not satisfy both, and the one that fails is the one measured by a score you never took.