10000, EVV Compliance Reviews
Revision 22-4; Effective Sept. 1, 2022
Payers conduct EVV compliance reviews to ensure 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
- Ensure valid phone type is used
- EVV Required Free Text (excluding the CDS option until further notice as determined by HHSC.)
- Document required free text
Refer to 7000 Clock In and Clock Out Methods, 9000 EVV Reason Code, and 11000 Usage for more information.
HHSC may change compliance requirements due to a natural disaster or at the discretion of HHSC.
Compliance Grace Periods
If program providers, FMSAs and CDS employers do not meet any of the 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 prior to 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 (if Option 3 on Form 1722, Employers Selection for Electronic Visit Verification Responsibilities) unless the CDS employer has read only access in the EVV system
- Complete all required visit maintenance before billing
- Train or re-train 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 Option 1 on Form 1722, Employers Selection for Electronic Visit Verification Responsibilities)
- Establish a process to monitor compliance reports with their FMSA (if Option 3 on Form 1722, Employers Selection for Electronic Visit Verification Responsibilities) unless they have read only access in the EVV system
- Train or re-train CDS employees on clock in and clock out methods
- Ask questions
State-Required Personal Care Services Grace Period
State-Required Personal Care Services are personal care services provided by program providers required to use EVV in 2016 or earlier per Texas Government Code, Section 531.024172.
The grace period dates of service for program providers started Sept. 1, 2019 and ended Aug. 31, 2020 and included:
- EVV Usage Reviews
Cures Act Personal Care Services Grace Period
Cures Act Personal Care Services are personal care services provided by program providers, FMSAs and CDS employers required to use EVV by Jan. 1, 2021 per the 21st Century Cures Act.
The grace period dates of service for program providers, FMSAs and CDS employers started Jan. 1, 2021 and ended Dec. 31, 2021 and includes:
- EVV Usage Reviews (Program provider and FMSA only)
- EVV Landline Phone Verification Reviews
- EVV Required Free Text Reviews (excluding the CDS option until further notice as determined by HHSC)
Due to availability of the EVV CDS Employer Usage report, the grace period dates of service for CDS employer EVV Usage Reviews started Jan. 1, 2021 and ended Aug. 31, 2022 unless noted by HHSC.
See Personal Care Services required to use EVV (PDF) on the EVV webpage for the complete list of services included in each grace period.
10010 EVV Usage Reviews
Revision 22-4; Effective Sept. 1, 2022
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.
A manually entered EVV visit transaction is an EVV visit that is manually entered into the EVV system when a service provider or CDS employee fails to use the EVV system to clock in when service delivery begins, clock out when service delivery ends, or both.
A rejected EVV visit transaction is an EVV visit transaction that is exported from an EVV system to the EVV Aggregator but is not accepted by the EVV Aggregator.
Refer to 8000 Visit Maintenance and 11000 Usage for more information.
Program Providers
The payers will use the EVV Usage Report (located 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 (located 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 Report (located in 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 11000 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 non-compliance to enforce one or more of the following progressive enforcement actions based on the number of occurrences within a 24-month period:
- First occurrence within a 24-month period - Require more EVV policy, system and portal trainings within 20 business days of receipt of the notice of non-compliance.
- The payer must review the EVV Usage Score for the following quarter from the date of the notice of non-compliance requiring 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.
- The payer must review the EVV Usage Score for the following quarter from the date of the notice of non-compliance requiring EVV training.
- Two or more occurrences within a 24-month period - Require completion of a CAP within ten business days of receipt of the notice of non-compliance
- 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.
- The payer must review the EVV Usage Score for the following quarter from the date of implementation of an accepted CAP.
- Three or more occurrences within a 24-month period - 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.
- Payers cannot terminate a contract unless:
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 ensure failure to meet and maintain the compliance score was not due to:
- Payer errors such as:
- Late authorizations
- Missing or incorrect HCPCS, Modifiers, Service Group and 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 non-compliance to enforce one or more of the following progressive enforcement actions based on the number of occurrences within a 24-month period:
- First occurrence within a 24-month period - Require additional 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 non-compliance requiring 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).
- The payer must review the EVV Usage Score for the following quarter from the date of the notice of non-compliance requiring additional EVV training.
- Two or more occurrences within a 24-month period - Require completion of a CAP with assistance from the FMSA within ten business days of the notice of non-compliance
- 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.
- The payer must review the EVV Usage Score for the following quarter from the date of implementation of an accepted CAP.
- Three or more occurrences within a 24-month period - Recommend removal from the CDS option
Before a payer enforcing action, payers must do their due diligence and ensure failure to meet and maintain the compliance score was not due to:
- FMSA administrative errors
- A system outage, defect or issue related to the EVV Aggregator, EVV Portal, an 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 but not limited to delivering:
- Notices of non-compliance 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
| Quarter Number | Review Period and State Fiscal Year Quarters Based on Date of Service | EVV Usage Review Dates |
|---|---|---|
| 1 | September, October, November | After the visit maintenance time frame has expired from the last date of the specified quarter, Nov. 30. |
| 2 | December, January, February | After the visit maintenance time frame has expired from the last date of the specified quarter, Feb. 28. or Feb. 29 if during a leap year. |
| 3 | March, April, May | After the visit maintenance time frame has expired from the last day of the specified quarter, May 31. |
| 4 | June, July, August | After the visit maintenance time frame has expired from the last day of the specified quarter, Aug. 31. |
EVV Usage Report
Payers will use the EVV Usage Report located 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 Report in the EVV Portal and EVV system.
Refer to 13000 Reports for more information.
State-Required Personal Care Services Grace Period
EVV Usage Reviews begin any time after the visit maintenance time frame has expired from the last day of the specified state fiscal year quarter. The grace period dates of service started Sept. 1, 2019 and ended Aug. 31, 2020 for these services.
Cures Act Personal Care Services Grace Period
EVV Usage Reviews begin after:
- The visit maintenance time frame has expired.
- The grace period has ended.
- The grace period dates of service started Jan. 1, 2021 and ended on Dec. 31, 2021 for program providers and FMSAs.
- Due to availability of the EVV CDS Employer Usage report, the grace period dates of service for CDS employers started Jan. 1, 2021 and end Aug. 31, 2022 unless noted by HHSC.
10020 EVV Landline Phone Verification Reviews
Revision 22-4; Effective Sept. 1, 2022
Payers review the phone number used for clocking in and clocking out of the EVV system to ensure 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 non-compliance 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 due to a CDS employer not meeting required actions outlined in 7030 Home Phone Landline, the FMSA must notify 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 non-compliance 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 non-compliance 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 day of notification by the FMSA:
- The FMSA can remove the unallowable landline phone type from the EVV system as the member’s home phone landline, and
- The FMSA can follow TAC 40, Part 1, Chapter 41, Subchapter B, Rule Section 41.221 relating 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 Report located in 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 13000 Reports for more information.
State-Required Personal Care Services Grace Period
There is no grace period for EVV Landline Phone Verification Reviews. Reviews 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.
Cures Act Personal Care Services Grace Period
EVV Landline Phone Verification Reviews will begin after the grace period has ended. The grace period dates of service started Jan. 1, 2021 and ended on Dec. 31, 2021.
10030 EVV Required Free Text Reviews
Revision 22-4; Effective Sept. 1, 2022
Payers will review EVV visit transactions to determine if required free text is entered when using a reason code.
Failure to document any required free text may result in recoupment of associated claim(s).
Refer to 9000 EVV Reason Code for more information.
Note: For the CDS option, as of Jan. 1, 2022 payers will not conduct Required Free Text Reviews until further notice as determined by HHSC.
Failure to Meet Compliance Standard
Program providers and FMSAs who fail to ensure required free text is entered into the EVV system prior to submitting an EVV claim may have associated claims recouped.
Review Period Schedule
The review period occurs any time after the visit maintenance time frame has expired and at the payer’s discretion.
EVV Reason Code Usage and Free Text Report or EVV Visit Log Report
Payers will use the EVV Reason Code Usage and Free Text Report or the EVV Visit Log Report (located in the EVV Portal) to conduct EVV Required Free Text Reviews.
Program providers and FMSAs must use the EVV Reason Code Usage and Free Text Report or the EVV Visit Log Report (located in the EVV Portal) to monitor compliance of required free text.
Refer to 13000 Reports for more information.
State-Required Personal Care Services Grace Period
There is no grace period for EVV Required Free Text Reviews. Reviews may begin any time after the visit maintenance time frame has expired.
Cures Act Personal Care Services Grace Period
EVV Required Free Text Reviews will begin after:
- The visit maintenance time frame has expired
- The grace period has ended
- The grace period started Jan. 1, 2021 and ended on Dec. 31, 2021
10040 HHSC EVV Informal Reviews and MCO Disputes
Revision 22-4; Effective Sept. 1, 2022
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 current HHSC 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
- Notifying 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 non-compliance by submitting a secure email request to the EVV Compliance inbox.
The request must include:
- The notice of non-compliance and the quarterly EVV Usage Report.
- Explanation of the basis for believing the EVV Compliance Review was not conducted according to TAC and EVV policies
- Any supporting documentation such as:
- Any relevant communication with TMHP, EVV vendors, 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 current HHSC EVV TAC and policies.
Contact your MCO for instructions on how to dispute the EVV Compliance Review results.
10050 Formal Appeal of HHSC Enforcement Actions
Revision 22-4; Effective Sept. 1, 2022
Per Texas Administrative Code Title 1, Part 15, Chapter 357, Subchapter I, Rule Section 357.484 program providers, FMSAs or CDS employers may request an administrative hearing in writing within 15 days after receipt of the notice of non-compliance 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, Texas 78714
Fax: 512-438-5759