8000 Visit Maintenance

Revision 22-4; Effective Sept. 1, 2022

Visit maintenance is the process used by the program provider, FMSA or CDS employer to correct an EVV visit transaction in the EVV system to accurately reflect the delivery of service. 

Program providers, FMSAs or CDS employers must complete all required visit maintenance. They must also ensure the EVV Aggregator accepts the visit transaction before the program provider or FMSA submits an EVV claim. If more visit maintenance is completed after submitting an EVV claim, program providers or FMSAs must submit an adjusted claim to match the updated visit transaction.

If the program provider or FMSA submits an EVV claim before required visit maintenance is complete, a payer may deny or recoup the EVV claim as part of contract oversight.

If the program provider or FMSA delegates visit maintenance responsibilities to a:

  • Third party such as a subcontractor, the program provider or FMSA is always responsible for actions taken by the third party. 
  • Third party, the program provider or FMSA ensures the third party follows all privacy and security protocols, including when the subcontractor or third-party accesses EVV data. 

If CDS employers delegate visit maintenance responsibilities to their designated representative (DR), the CDS employer is responsible for any actions taken by their DR. They must ensure that the DR follows all privacy and security protocols, including when the DR accesses EVV data.

8010 Required Visit Maintenance

Revision 22-4; Effective Sept. 1, 2022

Program providers, FMSAs or CDS employers must complete visit maintenance when the:

  • EVV system cannot “auto-verify” a visit transaction. 
  • EVV system identifies exceptions and critical errors.
  • EVV Aggregator rejects the EVV visit transaction due to incorrect or missing data. 
  • Program provider, FMSA or CDS employer reduces bill hours after the EVV system auto-verifies the EVV visit transaction.
  • EVV system is unavailable.
  • Service provider or CDS employee fails to use the EVV system.

Exceptions are identified by an EVV system and prevent an EVV visit transaction from being auto-verified or sent to the EVV Aggregator. 

Refer to 1400 Failure to Use an EVV System and 6000 EVV Visit Transaction for more information.

8020 Auto-Verification

Revision 22-4; Effective Sept. 1, 2022

Auto-Verification

Each time a service provider or CDS employee clocks in or clocks out during service delivery, the EVV system will: 

  • Capture visit data.
  • Verify the clock in and clock out method.
  • Compare critical data elements, including schedule data if applicable, in the EVV system.

If all visit data and identification data in the EVV system match, the system auto-verifies the EVV visit transaction which means there were no exceptions found. 

Refer to 4610 Schedule Types for information about how auto-verification works for each schedule type. 

If an EVV visit transaction is missing a clock in or a clock out and requires manually entered visit data, or if the data captured at the time of clock in or out does not match the critical data elements in the EVV system, the system cannot auto-verify an EVV visit transaction and will notify the program provider, FMSA or CDS employer of an exception. 

Clearing Exceptions 

The EVV system may generate one or more exceptions when the system cannot auto-verify the visit data captured at the time of clock in or clock out. 

To clear an exception, program providers, FMSAs or CDS employers must complete visit maintenance in the EVV system by: 

  • Updating the identification or visit data for a member, if applicable. Refer to 4400 Data Collection for more information.
  • Selecting the most appropriate EVV reason code(s), if required. 
  • Confirming the EVV visit.

Selecting the most appropriate EVV reason code(s) explains the reason for completing visit maintenance. The process involves: 

  • Selecting an EVV Reason Code Number.
  • Selecting an EVV Reason Code Description.
  • Entering required free text, if applicable.

Refer to 9000 EVV Reason Codes and Current HHSC EVV Reason Codes for more information.

The following are some examples that describe when the EVV system will not auto-verify an EVV visit:

  • Clock in or out time is missing
  • Clock in or out time does not match a schedule entered in the EVV system
  • An EVV visit is manually entered in to the EVV system 
  • Service providers or CDS employees clock in or clock out using a landline phone not registered in the member’s profile

Auto-Verification without a Schedule

If no schedule is entered in the EVV system, the EVV system will validate the following critical data elements:

  • Identity of the service provider or CDS employee
  • Identity of the member  
  • Actual hours worked
  • Clock in and out method(s)
  • Service type for the visit

If the above data elements match the data in the member’s profile, the visit will auto-verify without exceptions. 

If any of the above data elements do not match, the EVV system will not auto-verify the EVV visit and visit maintenance must be completed.

8030 EVV System Validation

Revision 22-1; Effective Jan. 7, 2022

Once the EVV system has verified a visit, it will conduct more system validation checks on the EVV visit transaction before sending the EVV visit transaction to the EVV Aggregator. 

The EVV system validation ensures the identification data and visit data is in the correct format. It compares the critical data elements to Texas Medicaid data stored at TMHP. 

An EVV system must perform the following validation before sending an EVV visit transaction to the EVV Aggregator:

  • Verifies that no required visit data elements are missing.
  • Verifies that all required visit data elements are in the correct format (length, alphanumeric, only valid values).
  • Verifies that all required identification data elements are in the correct format (NPI, API, Provider Number).
  • Verifies the service group and service code or HCPCS and modifier combination is valid for the member or EVV visit transaction.

If an EVV visit transaction fails the system validation, the EVV system will:

  • Not send the EVV visit transaction to the EVV Aggregator.
  • Notify the program provider, FMSA or CDS employer of the exceptions that must be corrected. 

To clear EVV system validation exceptions, the program provider, FMSA or CDS employer must complete visit maintenance. Once the program provider, FMSA or CDS employer clears the exceptions, the EVV system will send the EVV visit transaction to the EVV Aggregator for final processing.

8040 EVV Aggregator Validation

Revision 22-1; Effective Jan. 7, 2022

The EVV Aggregator performs many validations of all data elements on the EVV visit transaction. The EVV Aggregator validations include verifying the:

  • NPI or API for the program provider or FMSA to ensure it is active for the visit date.
  • Provider number is valid for the NPI or API on the visit date.
  • Member’s payer matches the Medicaid data.
  • Member has Medicaid eligibility for the visit date.
  • Service group, service code or HCPCS and Modifier on the visit date.

Based on the above validations, the EVV Aggregator will either accept or reject the EVV visit transaction received from an EVV system then display the status in the EVV Portal. 

After the EVV Aggregator accepts an EVV visit transaction, the program provider or FMSA can submit an EVV claim associated with the EVV visit transaction. 

When the EVV Aggregator rejects an EVV visit transaction, the EVV Aggregator returns the EVV visit transaction to the EVV system with the reason for the rejection. The program provider, FMSA or CDS employer must complete visit maintenance. After visit maintenance is complete the program provider or FMSA must resubmit the EVV visit transaction to the EVV Aggregator.

8050 Visit Maintenance Time Frame

Revision 22-4; Effective Sept. 1, 2022

Program providers, FMSAs and CDS employers must complete all required visit maintenance, including entry of manual EVV visits, within 95 days from the date of service delivery. This is known as the visit maintenance time frame. HHSC may extend the visit maintenance time frame as needed.

After the visit maintenance time frame has expired, the EVV system locks the EVV visit transaction and program providers, FMSAs or CDS employers may only complete visit maintenance if the payer approves a Visit Maintenance Unlock Request.

8060 Visit Maintenance Unlock Request 

Revision 22-4; Effective Sept. 1, 2022

A Visit Maintenance Unlock Request, when approved, allows a program provider, FMSA or CDS employer the opportunity to correct data element(s) on an EVV visit transaction(s) after the visit maintenance time frame has expired. 

The program provider, FMSA or CDS employer may request a payer unlock EVV visit transaction(s) for visit maintenance. If a request is submitted by an FMSA, the FMSA must ensure the CDS employer approves any corrections to time worked. If the request is submitted by a CDS employer, the CDS employer must notify their FMSA in writing (e.g., email).  

Approvals and denials of Visit Maintenance Unlock Requests are at the payer’s discretion and are determined on a case-by-case basis based on EVV policy or EVV system error. If the request is submitted by the CDS employer and the payer has approved or denied the request, the payer must also notify the FMSA in writing (e.g., email). 

Payers will only approve requests to manually enter and export an EVV visit after the visit maintenance time frame if:

  • The program provider was unable to manually enter and export an EVV visit during the visit maintenance time frame because of a payer or EVV vendor system error, and the error was not resolved within the visit maintenance time frame.
  • The CDS employer, or the FMSA on behalf of the CDS employer, was unable to manually enter and export an EVV visit during the visit maintenance time frame because of a payer, EVV vendor system, or EVV proprietary system error, and the error was not resolved within the visit maintenance time frame.
  • HHSC determines an exception is required for circumstances such as a natural disaster. 

When submitting a Visit Maintenance Unlock Request to create a manual visit due to a payer or EVV system error, the program provider, FMSA or CDS employer must provide evidence demonstrating:

  • They informed the payer of the error within the visit maintenance time frame.
  • The error was not resolved during the visit maintenance time frame.
  • They made a good faith effort to comply with the visit maintenance time frame. 

Making corrections to EVV visit transactions during a LTC FFS contract monitoring review or after it has occurred will not change any type of contract action such as recoupment or settlement reviews taken as result of the LTC FFS contract monitoring review.

Visit Maintenance Unlock Request Process

Program providers, FMSAs and CDS employers must complete the Visit Maintenance Unlock Request specific to their payer and service delivery option found on their payer’s website. 

Emails sent with a completed Visit Maintenance Unlock Request must be sent securely and include a contact name, email address and phone number. 

The program provider or FMSA can only select the following items from the ‘Incorrect Data Element’ column of their Visit Maintenance Unlock Request to be unlocked for correction:

  • Bill Hours
  • Contract Number
  • Employee ID
  • HCPCS Code/Modifier
  • Member Medicaid ID
  • NPI/API
  • Payer
  • Reason Code 
  • Service Code
  • Service Group
  • Units
  • Visit Location
  • N/A – Export Only

The CDS employer can only select the following items from the ‘Incorrect Data Element’ column of their Visit Maintenance Unlock Request to be unlocked for correction:

  • Bill Hours
  • Employee ID
  • HCPCS Code/ Modifier
  • Member Medicaid ID
  • Payer
  • Reason Code 
  • Service Code
  • Service Group
  • Units
  • Visit Location
  • N/A – Export Only

Initial Request to Payer

Payers must process Visit Maintenance Unlock Requests after receiving a secure and complete request from the program provider, FMSA or CDS employer within the following time frames:  

  • Ten business days 
  • Thirty business days if the request was submitted as supporting documentation for a MCO claims appeal

Email requests not sent securely will result in the payer denying the request due to a violation of the Health Insurance Portability and Accountability Act.

Contact the payer for assistance with sending a secure email request.

Payer Request for More Information

The payer may request more information from the program provider, FMSA or CDS employer, the request must be fulfilled within the following time frames of receipt: 

  • Ten business days 
  • Fifteen business days if the request is part of a MCO claims appeal.

If the program provider, FMSA or CDS employer does not fulfill the request within the established time frames, the payer may deny the request and a new Visit Maintenance Unlock Request must be submitted.

Payer Denial of Request

If the payer denies the request, the payer must notify the program provider, FMSA or CDS employer through email with the reason for the denial. The email notification must include at a minimum the following information on how to:

  • Submit a new Visit Maintenance Unlock Request
  • Request a claims appeal, if applicable
  • Submit a formal complaint against the payer

Payers may automatically deny a Visit Maintenance Unlock Request if the request:

  • Was not sent through a secure method
  • Is incomplete or missing required information
  • Could not be unencrypted
  • Was submitted using an outdated or modified version of the Visit Maintenance Unlock Request

Payer Approval of Request

If the payer approves the Visit Maintenance Unlock Request, the payer will send the approved Visit Maintenance Unlock Request to the EVV vendor or PSO. 

Only approved items on the Incorrect Data Element column of the Visit Maintenance Unlock Request will be unlocked for editing. 

EVV vendors or PSOs must only allow changes to the items approved by the payer.

Payer Incorrect, Incomplete or Retroactive Authorization Approvals

The payer must approve the Visit Maintenance Unlock Request when:

  • The payer previously provided incorrect or incomplete information on the prior authorization for a member and the updated authorization requires updates to EVV visit transactions outside of the EVV visit maintenance time frame. 
  • The payer submits a retroactive authorization for a member that will require the program provider, FMSA or CDS employer to resubmit an EVV visit transaction or EVV claim outside of the EVV visit maintenance time frame.
  • HHSC directs the payer to approve within the initial request time frame specified in this policy.

EVV Vendor and EVV PSO Approval and Denial

Once the EVV vendor or PSO receives the approved Visit Maintenance Unlock Request from the payer, the EVV vendor or EVV PSO must validate the information submitted. 

Once the information is validated: 

  • The EVV vendor has 10 business days from receipt of the approved Visit Maintenance Unlock Request to complete visit maintenance or schedule a meeting with the program provider, FMSA or CDS employer to complete visit maintenance.
  • The PSO must complete visit maintenance within 20 business days from receipt of the approved Visit Maintenance Unlock Request.

If the information submitted by the program provider, FMSA or CDS employer is incorrect, invalid or missing data elements, the EVV vendor or PSO will:

  • Not unlock EVV visit transaction(s) for visit maintenance.
  • Return the Visit Maintenance Unlock Request to the program provider, FMSA or CDS employer.
  • Notify the payer, program provider, FMSA or CDS employer of the reason the EVV visit transaction(s) cannot be unlocked for visit maintenance. 

EVV vendors and payers cannot provide specific information about what data elements should be updated. The EVV vendor can direct the program provider, FMSA or CDS employer to the visit dates and members that are approved within the Visit Maintenance Unlock Request and provide education about the EVV system. 

Once the information is corrected, the program provider, FMSA or CDS employer must submit a new Visit Maintenance Unlock Request to the payer.

Refer to the EVV webpage for the Visit Maintenance Unlock Request Job Aid for program providers, FMSAs or CDS employers.

8070 Visit Maintenance and Billing EVV Claims

Revision 22-4; Effective Sept. 1, 2022

A program provider, FMSA and CDS employer must ensure all required data elements are correct and visit maintenance is complete before the program provider or FMSA submit an EVV claim to the appropriate claims management system.  

If the program provider, FMSA or CDS employer needs to complete visit maintenance on an accepted EVV visit transaction that has already been billed, the program provider or FMSA must:

  • Complete visit maintenance on the EVV visit transaction(s).
  • Ensure the EVV Aggregator accepts the corrected EVV visit transaction.
  • Resubmit the EVV claim per the payer’s corrected claim process (e.g. negative bill the original claim and resubmit a corrected claim). 

The EVV Visit Maintenance Unlock Request does not override the timely filing deadline for submission of a new or corrected claim. If an exception to the timely filing deadline is needed, program providers or FMSAs must follow the process of their payer.

8080 Last Visit Maintenance Date

Revision 22-1; Effective Jan. 7, 2022

The Last Visit Maintenance Date field on the EVV visit transaction identifies the last date visit maintenance was completed. Payers may review the Last Visit Maintenance Date on the EVV visit transaction and the date and time TMHP received the associated EVV claim. 

If the Last Visit Maintenance Date is after the EVV claim receipt date, the EVV claim is subject to recoupment. To avoid recoupment, program providers and FMSAs must submit an adjusted claim if visit maintenance is completed after initial claim submission.

The EVV system will update the Last Visit Maintenance Date when any of the following fields are updated:  

  • API/NPI
  • Contract number
  • Member Medicaid ID
  • Service group
  • Service code
  • HCPCS code
  • Modifier
  • Bill hours
  • Units
  • Adding a Reason Code number
  • Adding a Reason Code description
  • Entering Reason Code free text  

The program provider or FMSA may review the Last Visit Maintenance Date on the EVV Visit Log Report and the EVV visit detail screen located in the EVV Portal.

8090 Rounding Rules

Revision 22-1; Effective Jan. 7, 2022

The EVV system calculates bill hours on an EVV visit transaction by rounding the actual hours worked to the nearest quarter hour increment. 

The EVV system rounds up to the next quarter hour increment when the actual hours worked are eight minutes or more than the previous quarter hour increment. The EVV system rounds down to the previous quarter hour increment when the actual hours worked are seven minutes or less from the previous quarter hour.

Actual Hours Worked Quarter Hour Increment Bill Hours 
0 - 7 minutes 0 minutes 0.00
8 - 22 minutes 15 minutes 0.25
23 - 37 minutes 30 minutes 0.50
38 - 52 minutes 45 minutes 0.75
53 - 67 minutes 60 minutes or 1 hour 1.00

Rounding rules examples:

  • If a service provider works two hours and 53 minutes of actual hours for a shift, the bill hours will round up to three hours.
  • If a service provider works two hours and 52 minutes of actual hours for a shift, the bill hours will round down to 2.75 hours.
  • If a service provider works four hours and 10 minutes of actual hours for a shift, the bill hours will round up to 4.25 hours.
  • If a service provider works four hours and six minutes of actual hours for a shift, the bill hours will round down to four hours.  

The EVV system does not round each clock in or clock out time. The EVV system only rounds the total duration of the actual hours worked for each visit.
The program provider, FMSA or CDS employer may downward adjust bill hours if the actual hours worked, captured in the EVV system, are incorrect or if the program provider or FMSA intends to bill Medicaid for less time than actual hours worked in the EVV system. 

The program provider, FMSA or CDS employer may never increase bill hours beyond the actual hours worked.

Program providers and FMSA must bill according to the EVV Service Bill Codes Table and follow program rules and policies, including any more program or MCO requirements regarding rounding.

8100 Visit Maintenance Reduction Features

Revision 22-3; Effective June 1, 2022

Visit maintenance reduction features help to reduce visit maintenance and increase auto-verification of an EVV visit transaction. 

Program providers and FMSAs who enter Daily Fixed or Daily Variable schedule types in the EVV system can turn on and off visit maintenance reduction features based on the selected schedule type. If an EVV PSO implements schedule types in their HHSC-approved EVV system, the EVV PSO may also implement visit maintenance reduction features.

Visit maintenance reduction features only apply when a schedule is entered in the EVV system. Refer to 4600 Schedules for more information.

Contact your EVV vendor to learn more about visit maintenance reduction features in the EVV system. 

Optional Expanded Time for Auto-Verification

The Optional Expanded Time for Auto-Verification is a feature that the program provider or FMSA can turn on in the EVV system. When this feature is turned on, the EVV system will auto-verify an EVV visit transaction if the duration of service delivery is no more than .25 bill hours greater or less than the scheduled duration with no exceptions or critical errors. 

An example of a scheduled EVV visit auto-verifying:

  • The schedule in the EVV system is 1 to 3 p.m., the duration of the scheduled visit is two hours. 
    • The program provider or FMSA has turned on the Optional Expanded Time for Auto-Verification in the EVV system.
    • The service provider or CDS employee clocked in at 12:45 p.m. and clocked out at 3 p.m.
    • The actual hours worked are two hours and 15 minutes which rounds to 2.25 bill hours.
    • The EVV system will auto-verify because 2.25 bill hours is .25 bill hours greater than the scheduled duration.

An example of a scheduled EVV visit not auto-verifying:

  • The schedule in the EVV system is 1 to 3 p.m., the duration of the scheduled visit is two hours. 
    • The program provider or FMSA has turned on the Optional Expanded Time for Auto-Verification in the EVV system.
    • The service provider or CDS employee clocked in at 12:45 p.m. and clocked out at 3:09 p.m.
    • The actual hours worked are two hours and 24 minutes which rounds to 2.50 bill hours.
    • The EVV system will not auto-verify because 2.50 bill hours is not within .25 bill hours of the scheduled duration.

Optional Automatic Downward Adjustment

The Optional Automatic Downward Adjustment is a feature that the program provider or FMSA can turn on to automatically downward adjust bill hours by .25 to match the duration of the scheduled visit. This feature is only available if the program provider or FMSA also turns on the Optional Expanded Time for Auto-Verification feature in the EVV system. 

The Optional Automatic Downward Adjustment feature only applies to bill hours and does not change actual hours worked.

For example:

  • The schedule in the EVV system is 1 – 3 p.m., the duration of the scheduled visit is two hours.
    • The program provider or FMSA has turned on the Optional Automatic Downward Adjustment and Optional Expanded Time for Auto-Verification.
    • The service provider or CDS employee clocked in at 12:45 p.m. and clocked out at 3 p.m.
    • The actual hours worked are two hours and 15 minutes which rounds to 2.25 bill hours.
    • 2.25 bill hours is within .25 bill hours of the scheduled duration.
    • The EVV system will auto-verify and automatically downward adjust the bill hours to 2.00.

Program providers, FMSAs or CDS employers must ensure the member’s plan of care is followed. Although visit maintenance reduction features are available and add flexibility, the needs of the member must always come first.

For example, if a member needs their service provider or CDS employee to be at the home at the scheduled time of 8 a.m. to receive help getting out of bed, the service provider or CDS employee must be there on time. The program provider, FMSA and CDS employer must document all situations as needed and in accordance with program policy and licensure requirements.