11000, EVV Compliance Reviews | Texas Health and Human Services (2024)

Revision 24-1; Effective Sept. 12, 2024

Payers conduct EVV compliance reviews to make sure program providers, FMSAs and CDS employers are in compliance with EVV requirements and policies.

Payers will not start reviews until the visit maintenance time frame has expired.

Payers will conduct reviews and initiate contract or enforcement action if the program providers, FMSAs or CDS employers do not meet any of the following EVV compliance requirements:

• EVV Usage
  • Meet the minimum EVV Usage Score
• EVV Landline Phone Verification
  • Make sure valid phone type is used

Refer to 7000 Clock In and Clock Out Methods, 10000 Reason Codes and 12000 Usage for more information.

HHSC may change compliance requirements because of a natural disaster or at the discretion of HHSC.

Compliance Grace Periods

Under certain circ*mstances, HHSC may choose to suspend certain compliance requirements. If program providers, FMSAs and CDS employers do not meet the suspended EVV compliance requirements during the compliance grace period, payers will not initiate enforcement action unless noted by HHSC.

Payers will post a notice on their websites 90 days before the start of reviews.

During the Compliance Grace Periods

Program providers and FMSAs must monitor compliance reports monthly, at a minimum, in the EVV portal and perform the following:

• Use the EVV system as required
• Establish a process to monitor compliance reports with their CDS employer, unless the CDS employer has chosen Option 3 on Form 1722, Employers Selection for Electronic Visit Verification Responsibilities has read-only access in the EVV system
• Complete all required visit maintenance before billing
• Train or retrain service providers on clock in and clock out methods, specific to program providers only. Refer to 4240 Training Requirements for Service providers and CDS Employees
• Ask questions

The CDS employer must monitor compliance reports monthly, at a minimum, in the EVV system and perform the following:

• Use the EVV system as required
• Complete all required visit maintenance if they have chosen Option 1 on Form 1722, Employers Selection for Electronic Visit Verification Responsibilities
• Establish a process to monitor compliance reports with their FMSA, unless they have chosen Option 3 on Form 1722, Employers Selection for Electronic Visit Verification Responsibilities and have read-only access in the EVV system
• Train or retrain CDS employees on clock in and clock out methods
• Ask questions

11010 EVV Usage Reviews

Revision 24-1; Effective Sept. 12, 2024

Payers review the EVV Usage Score quarterly.

EVV Usage Reviews are conducted after the visit maintenance time frame has expired based on the last date of the quarter to determine compliance.

The EVV Usage Score measures manually entered EVV visit transactions and rejected EVV visit transactions.

Refer to 9000 Visit Maintenance and 12000 Usage for more information.

Program Providers

The payers will use the EVV Usage Report in the EVV Portal to determine the EVV Usage Score for each program provider’s contract with HHSC and the MCOs.

FMSAs

The payers will use the EVV FMSA Usage Report in the EVV Portal to determine the EVV Usage Score for each FMSAs contract with HHSC and the MCOs.

CDS Employers

The payers will use the EVV CDS Employer Usage Reportin the EVV Portal and the EVV System to determine the EVV Usage Score for each Medicaid member that selects the CDS option with HHSC or an MCO.

Refer to 12000 Usage for more information.

Failure to Meet the Compliance Standard

Failure to meet the compliance standard may result in the following actions.

Program Provider and FMSA Enforcement Actions

When a program provider or FMSA fails to meet and maintain the minimum EVV Usage Score of 80% in a state fiscal year quarter, the payer may send a notice of noncompliance to enforce one or more of the following progressive enforcement actions based on the number of occurrences within a 24-month period:

• For the first occurrence within a 24-month period, the payer will require more EVV policy, system and portal trainings within 20 business days of receipt of the notice of noncompliance.
  • The payer must review the EVV Usage Score for the following quarter from the date of the notice of noncompliance, which requires EVV training.
    • If the minimum EVV Usage Score is met, no further action will be taken by the payer for the compliant quarter.
    • If the minimum EVV Usage Score is not met, the payer may document and apply a CAP.
• When there are two or more occurrences within a 24-month period, the payer will require the program provider or FMSA to complete a CAP within 10 business days of receipt of the notice of noncompliance.
  • The payer must review the EVV Usage Score for the following quarter from the date of implementation of an accepted CAP.
    • If the minimum EVV Usage Score is met, no further action will be taken by the payer for the compliant quarter.
    • If the minimum EVV Usage Score is not met, the payer may initiate contract termination.
• When there are three or more occurrences within a 24-month period, the payer may propose to terminate contract.
  • Payers cannot terminate a contract unless:
    • The payers have followed the above progressive enforcement actions.
    • The program provider or FMSA has not met the minimum EVV Usage Score for a total of three quarters, nine months, within in a 24-month period.

When the program provider or FMSA fails to complete training or CAP requirements as explained above, the payer may temporarily withhold Medicaid claims payments until requirements are met.

Before a payer enforcing action, payers must do their due diligence and make sure failure to meet and maintain the compliance score was not because of:

• Payer errors such as:
  • Late authorizations
  • Missing or incorrect HCPCS, Modifiers, Service Group or Service Codes provided by the payer
• A system outage, defect or issue related to the EVV Aggregator, EVV Portal or an EVV Vendor System
• Natural disasters

CDS Employer Enforcement Actions

When a CDS employer fails to meet and maintain the minimum EVV Usage score in a state fiscal year quarter, the payer may send a notice of noncompliance to enforce one or more of the following progressive enforcement actions based on the number of occurrences within a 24-month period:

• For the first occurrence within a 24-month period, the payer will require more EVV policy and system trainings within a specific time frame.
  • The payer must review the EVV Usage Score for the following quarter from the date of the notice of noncompliance, which requires additional EVV training.
    • If the minimum EVV Usage Score is met, the payer takes no further action for the compliant quarter.
    • If the minimum EVV Usage Score is not met, the payer may document and apply a corrective action plan (CAP).
• When there are two or more occurrences within a 24-month period, the payer will require the CDS employer to create a CAP with help from the FMSA within 10 business days of the notice of noncompliance.
  • The payer must review the EVV Usage Score for the following quarter from the date of implementation of an accepted CAP.
    • If the minimum EVV Usage Score is met, the payer takes no further action for the compliant quarter.
    • If the minimum EVV Usage Score is not met, the payer may recommend removal from the CDS option.
• When there are three or more occurrences within a 24-month period, the payer may recommend removal from the CDS option.

Before a payer enforcing action, payers must do their due diligence and make sure failure to meet and maintain the compliance score was not because of:

• Payer errors such as:
  • Late Authorizations
  • Missing or incorrect HCPCS, Modifiers, Service Group or Service Codes
• FMSA administrative errors
• A system outage, defect or issue related to the EVV Aggregator, EVV Portal, the EVV Vendor System or an EVV Proprietary System
• Natural disasters

FMSAs are responsible for facilitating communication between payers and CDS employers related to EVV compliance including delivering:

• Notices of noncompliance from a payer to a CDS employer
• Responses from a CDS employer back to the payer

Review Period Schedule

The EVV usage review period schedule follows the state fiscal year quarters. Payers may begin reviews any time after the visit maintenance time frame has expired for the specified state fiscal year quarter.

EVV Usage Review Period Schedule

EVV Usage Report

Payers will use the EVV Usage Report in the EVV Portal to conduct EVV Usage Reviews for visits with a date of service within the Review Period.

Program providers and FMSAs have access to the EVV Usage Report in the EVV Portal.

FMSAs have access to the EVV FMSA Usage Report in the EVV Portal.

FMSAs and CDS employers have access to the EVV CDS Employer Usage Reportin the EVV Portal and EVV system.

Refer to 14000 Reports for more information.

11020 EVV Landline Phone Verification Reviews

Revision 24-1; Effective Sept. 12, 2024

Payers review the phone number used for clocking in and clocking out of the EVV system to make sure the phone number is from an allowable phone type.

Refer to 7000 Clock In and Clock Out Methods for more information.

Failure to Meet the Compliance Standard

Failure to meet required actions outlined in 7030 Home Phone Landline and in the notice of noncompliance sent by the payer may result in the payer temporarily withholding Medicaid claims payments from the program provider or FMSA until compliance is met.

If the FMSA is unable to meet required actions because of a CDS employer not meeting required actions outlined in 7030 Home Phone Landline, the FMSA must tell the payer immediately in writing by email or fax.

Program Provider and FMSA Enforcement Actions

When the program provider or FMSA fails to meet required actions within 20 business days of the notice of noncompliance sent by the payer, the payer may temporarily withhold Medicaid claims payments from the program provider or FMSA.

Payers will remove the temporary withholding of Medicaid claims payments within two business days of receiving acceptable documentation as outlined in the notice of noncompliance sent by the payer and described in 7030 Home Phone Landline.

CDS Employer Enforcement Actions

When the CDS employer fails to meet required actions within 10 business days of notification by the FMSA:

• The FMSA may remove the unallowable landline phone type from the EVV system as the member’s home phone landline, and
• The FMSA may follow26 TAC, Part 1, Chapter 264, Subchapter B, Section 264.221, Corrective Action Plans, which relates to failure to submit complete service delivery documentation or meeting CDS employer responsibilities and place the CDS employer on a CAP.

Review Period Schedule

EVV Landline Phone Verification Reviews will be at the payer’s discretion. It may occur any time after the date of the visit if the phone number used to clock in and clock out has already been captured in the EVV system.

Refer to 7000 Clock In and Clock Out Methods for more information.

EVV Landline Phone Verification Report

Payers will use the EVV Landline Phone Verification Reportin the EVV system to conduct EVV Landline Phone Verification Reviews.

Program providers, FMSAs and CDS employers who have selected Option 1 or 2 on Form 1722, Employers Selection for Electronic Visit Verification Responsibilities, have access to the EVV Landline Phone Verification Report in the EVV system.

CDS employers who selected Option 3 on Form 1722, Employers Selection for Electronic Visit Verification Responsibilities, must establish a process to get the EVV Landline Phone Verification Report with their FMSA. This does not apply if the CDS Employer has read only access to the EVV system. Contact your FMSA for more information.

Refer to 14000 Reports for more information.

11030 HHSC EVV Informal Reviews and MCO Disputes

Revision 24-1; Effective Sept. 12, 2024

HHSC EVV Informal Reviews

Program providers, FMSAs and CDS employers

Program providers, FMSAs and CDS employers may request an informal review of EVV Compliance Review results for re-examination if they:

• disagree with the EVV compliance review findings provided by HHSC; and
• believe the review did not adhere to EVV TAC and policies.

EVV Informal Reviews are:

• Conducted to re-examine the disputed results
• Conducted by HHSC EVV Operations staff who were not involved in the review under question
• Completed within 20 business days of the request receipt date

The EVV Informal Reviews process includes the following activities:

• Acknowledgment of receipt through email of the EVV Informal Reviews request
• Establishing the informal review team
• Conducting the EVV Informal Reviews
• Telling the program provider, FMSA or CDS employer in writing of the EVV Informal Reviews results

The results of the EVV Informal Review are final.

Requesting an EVV Informal Review

Program providers, FMSAs or CDS employers may request EVV Informal Reviews within 10 business days after receipt of the notice of noncompliance by submitting a secure email request to theEVV Compliance inbox.

The request must include:

• The notice of noncompliance and the quarterly EVV Usage Report.
• Explanation of the basis for believing the EVV Compliance Review was not conducted according to EVV TAC and policies
• Any supporting documentation such as:
  • Any relevant communication with TMHP, the EVV vendor, payers, FMSAs or CDS employers
  • Documentation of relevant EVV system issues
  • Any other documentation that supports the program provider’s, FMSA’s or CDS employer’s disagreement with the EVV Compliance Review results

Failure to follow the steps above will result in HHSC denying the EVV Informal Review request.

MCO Disputes

Program providers, FMSAs and CDS employers

Program providers, FMSAs and CDS employers may request a dispute of the EVV Compliance Review results for re-examination with their MCO if they:

• disagree with the EVV compliance review findings provided by an MCO; and
• believe the review did not adhere to EVV TAC and policies.

Contact your MCO for instructions on how to dispute the EVV Compliance Review results.

11040 Formal Appeal of HHSC Enforcement Actions

Revision 24-1; Effective Sept. 12, 2024

Per 1 TAC, Part 15, Chapter 357, Subchapter I, Section 357.484, Request for a Hearing, program providers, FMSAs or CDS employers may request an administrative hearing in writing within 15 days after receipt of the notice of noncompliance if appealing the withholding of Medicaid claims payments.

Send the written request to:
Texas Health and Human Services Commission
Legal Services
Office of General Counsel
P.O. Box 149030
Mail Code W-615
Austin, TX 78714
Fax: 512-438-5759