Comparison of Georgia Care Management Organization Encounter Data to Cash Disbursements for Amerigroup Community Care
Learn how the AI-generated research projects were createdOverall Conclusion
The engagement is framed as a consulting study not an audit, with findings indicating that most reconciliation totals align closely to CDJs while highlighting notable data quality issues that affect GF 360 completion percentages and several delegated vendor categories. While several vendor areas (CarelonRx and DentaQuest) approach compliance, missing encounters, misallocated program indicators, and unmatched CDJ-encounter mappings indicate ongoing data integrity risks. The results underscore the need for ongoing remediation and stronger data governance between Amerigroup, DCH, the FAC, and its vendors to achieve consistent ≥99% completion across all programs in future periods.
Source Document
Audit Scope
Review of Amerigroup Georgia Families and Georgia Families 360 encounter data submitted to the FAC MMIS through Gainwell Technologies for the period April 1, 2024 through March 31, 2026 (with encodings and adjustments through May 4, 2026), including entire plan, delegated vendors (CarelonRx, DentaQuest, Avesis Vision), and fee-for-service (non-vendor) paid encounters; comparison to CDJ totals; and documentation of data issues and recommended corrective actions.
Key Findings Summary
Avesis Vision encounters show completion below 99% (Avesis Vision cumulative 98.11%), contributing to non-compliance in that delegated vendor category.
Georgia Families overall completion meets the 99% minimum (99.35%) for the entire plan, but Georgia Families 360 completion is 97.47% for the entire plan, indicating non-compliance for GF 360 in the aggregated data.
CarelonRx overall completion is in compliance (99.76% cumulative), but sections note missing or potentially missing voids and CDJ transactions in certain months that could overstate or understate completion in February 2025 and September 2024.
View the Findings tab to see all 6 findings
AI-Assisted
AI Scope Summary
The study aims to verify that Amerigroup Georgia Families and Georgia Families 360 encounters paid within the April 1, 2024 through March 31, 2026 period meet the state contract minimum completeness of 99% when reconciled to CDJs, while evaluating completeness by program segment (entire plan, each delegated vendor, and fee-for-service non-vendor), identifying data issues that could affect accuracy, and outlining remediation steps for future audits to strengthen encounter-to-CDJ reconciliation and governance.
AI-Generated Insight
The report emphasizes reconciliation between encounters and CDJs across Georgia Families and Georgia Families 360, showing high overall alignment but persistent data quality issues in GF 360 and some delegated vendors. Focus areas for future audits include improving program mapping, void handling, missing encounters, and cross-vendor data integrity to sustain ≥99% completion.
Audit Objectives
Review Amerigroup Georgia Families and Georgia Families 360 encounters paid within April 1, 2024 through March 31, 2026 and compare to the corresponding Cash Disbursement Journals (CDJ) to determine if paid encounters meet the state contract minimum completeness requirement of 99 percent when compared to CDJ files submitted by the CMO.
Analyze encounter data submitted by CMOs to the FAC's MMIS data warehouse and identify adjustments for duplicates and voids, ensuring net encounter totals align with CDJ submissions for reconciliation.
Evaluate completeness across entire plan, each delegated vendor, and fee-for-service (non-vendor) categories for Georgia Families and Georgia Families 360, including CarelonRx, DentaQuest, Avesis Vision, and others, within the study period.
Identify data quality issues affecting completion percentages (e.g., missing encounters, missing CDJs, mismatched program identifiers) and provide actionable recommendations to Amerigroup and the Georgia Department of Community Health (DCH) for remediation.
Provide a data-driven basis for future Medicaid audits of encounter-to-CDJ reconciliations, including specific areas for process improvement and controls.
Audit Findings (6)
Avesis Vision encounters show completion below 99% (Avesis Vision cumulative 98.11%), contributing to non-compliance in that delegated vendor category.
Georgia Families overall completion meets the 99% minimum (99.35%) for the entire plan, but Georgia Families 360 completion is 97.47% for the entire plan, indicating non-compliance for GF 360 in the aggregated data.
CarelonRx overall completion is in compliance (99.76% cumulative), but sections note missing or potentially missing voids and CDJ transactions in certain months that could overstate or understate completion in February 2025 and September 2024.
DentaQuest completion is compliant (GF 360 DentaQuest around 97.66% monthly fluctuations; cumulative 99.37%), but data issues such as missing or denied encounter adjustments and unmatched CDJs can affect monthly percentages.
Data issues noted in Section A and B include missing encounter sequences, misallocated program indicators, unmatched CDJ-encounter indicators, and potential missing CDJ voids, which may impact the calculated completion percentages.
The analysis notes that ModivCare non-emergency transportation was removed from Amerigroup totals per DCH direction, reducing external totals and affecting comparability.
Recommendations (8)
Continue to work with the Georgia Department of Community Health (DCH) and the FAC (Gainwell Technologies) to identify potentially missing encounters or CDJs and correct mismatches in program identifiers between encounters and CDJs.
Work with CarelonRx to (re)submit any potentially missing or corrected encounters and CDJ transactions, including voids.
Work with DentaQuest to identify and resubmit any missing or denied encounter adjustments and CDJ records.
Work with Avesis Vision to identify and submit any missing encounter sequences and address unmatched CDJ-encounter indicators.
Ensure accurate separation of CDJ data by program where feasible, and re-evaluate any cross-program aggregation that may obscure region-specific reconciliation results.
Exclude referral fees, management fees, and other non-encounter related fees from the CDJ data in future submissions, as already instructed in Appendix B.
Document and maintain controls to identify and remove ModivCare non-emergency transportation from totals in accordance with DCH direction.
Enhance data submission controls and validation processes to detect and prevent missing or duplicated encounters, and ensure voids align with adjustment dates.