Evidence record
Comparison of Georgia Care Management Organization Encounter Data to Cash Disbursements for Amerigroup Community Care
- Jurisdiction
- Georgia
- Publishing agency
- Myers and Stauffer LC
- Publication date
- May 21, 2026
- Source record
- Original document linked
Findings
6
Recommendations
8
Overall 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.
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.
Findings (6)
Each finding has a stable link.
- F-1288
Avesis Vision encounters show completion below 99% (Avesis Vision cumulative 98.11%), contributing to non-compliance in that delegated vendor category.
- F-1287
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.
- F-1289
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.
- F-1290
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.
- F-1291
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.
- F-1292
The analysis notes that ModivCare non-emergency transportation was removed from Amerigroup totals per DCH direction, reducing external totals and affecting comparability.
Recommendations (8)
- R-1133
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.
Related finding F-1291 - R-1134
Work with CarelonRx to (re)submit any potentially missing or corrected encounters and CDJ transactions, including voids.
Related finding F-1289 - R-1135
Work with DentaQuest to identify and resubmit any missing or denied encounter adjustments and CDJ records.
Related finding F-1290 - R-1136
Work with Avesis Vision to identify and submit any missing encounter sequences and address unmatched CDJ-encounter indicators.
Related finding F-1288 - R-1137
Ensure accurate separation of CDJ data by program where feasible, and re-evaluate any cross-program aggregation that may obscure region-specific reconciliation results.
Related finding F-1291 - R-1138
Exclude referral fees, management fees, and other non-encounter related fees from the CDJ data in future submissions, as already instructed in Appendix B.
- R-1139
Document and maintain controls to identify and remove ModivCare non-emergency transportation from totals in accordance with DCH direction.
Related finding F-1292 - R-1140
Enhance data submission controls and validation processes to detect and prevent missing or duplicated encounters, and ensure voids align with adjustment dates.
Related finding F-1291