13000, EVV Claims

Revision 24-1; Effective Sept. 12, 2024

The program provider or FMSA must only submit claims for reimbursement once all the visits for the claim line items have been completed and accepted in the EVV Aggregator. The EVV Aggregator will perform a claims match against the accepted EVV visit transactions stored in the EVV Portal.

The payer must not pay a claim without a matching accepted EVV visit transaction stored in the EVV Portal.

13010 Claims Submission

Revision 24-1; Effective Sept. 12, 2024

All EVV services listed in the EVV Service Bill Codes Table on the HHSC EVV webpage are subject to this policy.

Each claims management system will forward the EVV claims to the EVV Aggregator for the EVV claims matching process. The EVV Aggregator will return the EVV claims and the EVV claims match result code(s) back to the claims management system for further claims processing.

Program providers and FMSAs must:

• Follow the billing guidelines of their payer, either HHSC or their MCO, when they submit an EVV claim.
• Submit EVV claims per claim line item with either a single date of service or a span of dates as required by their payer billing guidelines. Refer to 13020 Claims Matching for more information about how the EVV Aggregator performs the EVV claims match for each type of billing.
• Tell the third-party submitter of 13010 Claims Submission requirements when using a third-party claims submitter or billing agent.
• Submit EVV claims for the program and services as detailed in the tables below.
• Meet all timely filing requirements.

LTC FFS

Program providers and FMSAs must submit EVV claims for LTC FFS to the TMHP Claims Management System for the following programs and services.

Acute Care FFS

Program providers and FMSAs must submit EVV claims for Acute Care FFS to the TMHP Compass 21 (C21) system for the following programs and services.

YES

Program providers must submit EVV Claims for YES to the HHSC Clinical Management for Behavioral Health Services (CMBHS) system for the following program service.

HCBS-AMH Waiver

Program providers must submit EVV claims for HCBS-AMH to HHSC using an Encounter Invoice Template for the following program services.

Managed Care Long-Term Services and Supports (LTSS)

Program providers and FMSAs must submit EVV claims to TMHP C21 for the following managed care programs and services.

Access the EVV Contact Information Guide (PDF) on the HHSC EVV webpage to find who to contact for other questions about the EVV claims submission process.

Program providers and FMSAs can access TMHP’s EDI homepage for basic information needed to submit claims electronically including:

• User guides
• Forms
• Technical information intended for billing agents that file claims on behalf of program providers and FMSAs

13020 Claims Matching

Revision 24-1; Effective Sept. 12, 2024

All EVV claims for EVV-required services must match an accepted EVV visit transaction in the EVV Aggregator, the state’s centralized EVV database, before reimbursement of an EVV claim by the payer. TMHP, the claims administrator for the state of Texas, oversees this process.

Payers will deny or recoup an EVV claim that does not match an accepted EVV visit transaction. This includes fee-for-service claims paid by HHSC, acute care claims paid by TMHP on behalf of HHSC and managed care claims paid by the MCO.

Program providers and FMSAs that use a third party to bill claims must tell the third party that all claims for EVV required services must be submitted to TMHP.

13030 Claims Matching Process

Revision 24-1; Effective Sept. 12, 2024

HHSC uses the EVV claims matching process to identify one or more EVV visits that support a Medicaid claim. Once a program provider or FMSA submits an EVV claim to a claims management system operated by HHSC or TMHP, the claims management system forwards any claims for EVV services to the EVV Aggregator for the claims matching process.

The automated claims matching process includes:

• Receiving an EVV claim line item.
• Matching data elements from each EVV claim line item to data elements from one or more accepted EVV visit transactions in the EVV Aggregator.
• Forwarding an EVV claim match result code to the payer once the claims match process is complete.

Program providers and FMSAs must use the EVV Portal to review and confirm the EVV Aggregator has accepted the EVV visit transactions before they submit the EVV claim(s) for those services.

The following data elements from the claim line item and the EVV visit transaction must match.

If any of the above data elements do not match, the claim matching process will return an unsuccessful match result code and the payer will deny the claim.

The EVV claims matching process supports EVV claims submitted with a single date of service and EVV claims submitted with a span of service dates.

Unit Matching for Multiple Visits on the Same Date of Service

If there are multiple visits for the same member for the same service, HCPCS and Modifier combination, from the same provider on the same date of service, the claims matching process combines the total number of units on all accepted EVV visits for that date and compares the unit total to the billed units on the claim line item.

Unit Matching Requirement for EVV Claims with Single Line Item

Program providers and FMSAs who submit EVV claims with a single EVV claim line item for each date of service must have one or more matching accepted EVV visit transactions for the same date in the EVV Aggregator or the payer may deny or recoup the EVV claim line item.

Unit Matching Requirement for EVV Claims with Span Dates of More Than One Consecutive Date

Program providers and FMSAs who submit an EVV claim with a span of dates for a line item must make sure:

• Each date of service within the span of dates has one or more matching EVV visit transactions accepted in the EVV Aggregator.
• The total units on the EVV claim line item must match the combined total units on the accepted EVV visit transactions for the span of dates, if applicable.

The payer will deny or recoup an EVV claim line item with span dates that does not meet the above criteria.

13040 Exceptions to the Claims Matching Process

Revision 24-1; Effective Sept. 12, 2024

HHSC will establish any exceptions to the claims matching process in the EVV Service Bill Codes Table.

Service-Specific Bypass

HHSC will bypass the claims matching process for specific services. Refer to the EVV Service Bill Codes Table for the specific services that bypass the claims matching process.

Units Matching Bypass

The EVV claims matching process does not match units on the EVV visit transaction against the billed units on the EVV claim line item for any of the services associated with the CDS option.

In addition, the claims matching process does not match units on the EVV visit transactions against the billed units on the claim line item for other specific services. Refer to the EVV Service Bill Codes Table for the specific services that bypass the units matching process.

Bypass for Disasters and Temporary Circumstances

HHSC may temporarily set the EVV claims matching process to bypass EVV claims in response to a disaster or temporary circumstances that may disrupt delivery of services. In such cases, HHSC will provide written direction to program providers and FMSAs, including the effective dates of the bypass.

13050 Claims Match Result Codes

Revision 24-1; Effective Sept. 12, 2024

Claims Match Result Codes are codes used to indicate if an EVV claim line item matched or did not match to an accepted EVV visit transaction.

Based on the result of the claims matching process, the EVV Portal displays a claims match result code and the EVV Aggregator returns the claims match result code to the claims management system for final claims processing.

The claims match result codes viewable in the EVV Portal are:

• EVV01 – EVV Successful Match
• EVV02 – Medicaid ID Mismatch
• EVV03 – Visit Date Mismatch
• EVV04 – Provider (NPI/API) or Attendant ID Mismatch
• EVV05 – Service Mismatch, including HCPCS and Modifiers if applicable
• EVV06 – Units Mismatch
• EVV07 – Match Not Required
• EVV08 – Natural Disaster

Payers will communicate the results of the final claims processing to program providers and FMSAs.

Claims Match Result Code EVV01

If the EVV Aggregator identifies one or more accepted EVV visit transactions matching the EVV claim line item, the claims matching process will return an EVV01 – EVV Successful Match result code.

Payers may still deny or recoup an EVV claim with a claims match result code EVV01 if other claim requirements fail the claims adjudication process.

For example:

• Payers may deny an EVV claim if the amount billed exceeds the authorized amount for the member.
• Payers may recoup an EVV claim if the program provider or FMSA changes EVV visit data after an EVV visit transaction matched and an updated EVV claim is not submitted by the program provider or FMSA.

Claims Match Result Codes EVV02 – EVV06

If the EVV Aggregator identifies a mismatch between an accepted EVV visit transaction and an EVV claim line item, the claims matching process will return one of the claims match result codes of EVV02, EVV03, EVV04, EVV05 or EVV06.

The payer will deny an EVV claim if the EVV claim line item receives a claims match result code of EVV02, EVV03, EVV04, EVV05 or EVV06.

Claims Match Result Codes EVV07 and EVV08

When HHSC implements a bypass of the claims matching process for a disaster or other temporary circumstance the claims matching process will return claims match result codes of EVV07 or EVV08.

Payers will not deny an EVV claim with EVV07 or EVV08 claims match result codes for an unsuccessful match.

Payers may still deny an EVV claim with claims match result codes EVV07 or EVV08 if other claim requirements fail the claims adjudication process.

When HHSC bypasses the claims matching process, the EVV Aggregator will still perform the claims matching process between the EVV claim line item and the EVV visit transaction to record the actual claims match results. Program providers and FMSAs can view the actual claims match results in the EVV Portal to find out if the EVV claim would have matched without the bypass.

Payers may recoup the EVV claim if the program provider or FMSA does not follow instructions from the payer related to claims match result codes EVV07 or EVV08.

Claims Status Report

Payers will return a claims status report for each EVV claim. The claims status report includes claims match result codes and the final claims processing result. This may include an Explanation of Benefit (EOB), Explanation of Payment (EOP) or a Denial Claims Report. Claims status reports differ by the payer and program.

See the table below for the claims management system responsible for reporting EVV claims status.

Refer to the Contact Information Guide on the HHSC EVV webpage to find who to contact with questions about the claims matching process or EVV claim denials.