Revision 25-1; Effective March 12, 2025

Program providers, FMSAs or CDS employers must complete all required visit maintenance. They must also make sure the EVV Aggregator accepts the visit transaction before the program provider or FMSA submits an EVV claim. If more visit maintenance is completed after an EVV claim is submitted, program providers or FMSAs must submit an adjusted claim to match the updated EVV 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.
  • makes sure 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 make sure the DR follows all privacy and security protocols, including when the DR accesses EVV data.

9010 Required Visit Maintenance

Revision 25-1; Effective March 12, 2025

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

  • EVV system cannot auto-verify an EVV visit transaction.
  • EVV system identifies data errors.
  • EVV Aggregator rejects the EVV visit transaction because of 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.
  • FMSA overrides the EVV system with the payroll system.

Data errors 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.

Program providers, FMSAs and CDS employers cannot make changes to the following data fields during visit maintenance:

  • Actual service delivery date
  • Actual service delivery clock in time
  • Actual service delivery clock out time
  • Actual hours worked
  • GPS coordinates

9020 Auto-Verification

Revision 25-1; Effective March 12, 2025

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 no exceptions were 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 tell the program provider, FMSA or CDS employer of an exception.

A service provider may clock in and clock out when no service authorization is in the EVV system if the EVV system allows.

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 10000 Reason Codes and the Current HHSC EVV Reason Codes for more information.

The following examples 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 into the EVV system
  • Service providers or CDS employees use a landline phone not registered in the member’s profile to clock in or clock out

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.

9030 EVV System Validation

Revision 25-1; Effective March 12, 2025

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

The EVV system validation makes sure 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 it sends an EVV visit transaction to the EVV Aggregator that verifies:

  • no required visit data elements are missing.
  • all required visit data elements are in the correct format, such as length, alphanumeric and only valid values.
  • all required identification data elements are in the correct format, such as NPI, API and Provider Number.
  • 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.
  • Tell the program provider, FMSA or CDS employer the data errors that must be corrected.

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

The program provider, FMSA or CDS employer may, if appropriate, inactivate visits before the visit is accepted by the aggregator. Inactivated visits will not be included in the Standard Reports listed in Section 14010, EVV Portal Standard Reports.

9040 EVV Aggregator Validation

Revision 24-1; Effective Sept. 12, 2024

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 make sure 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 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.

A rejected EVV visit transaction is exported from an EVV system to the EVV Aggregator but is not accepted by the EVV Aggregator. 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.

9050 Visit Maintenance Time Frame

Revision 25-1; Effective March 12, 2025

Program providers, FMSAs and CDS employers must complete all required visit maintenance, including entry of manual EVV visits, within 95 calendar 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.

9060 Visit Maintenance Unlock Request

Revision 25-1; Effective March 12, 2025

A Visit Maintenance Unlock Request, when approved, allows a program provider, FMSA, CDS employer or PSO 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, CDS employer or PSO may request a payer unlock EVV visit transaction(s) for visit maintenance. If an FMSA submits the request on behalf of a CDS employer, the FMSA must make sure the CDS employer approves any corrections to time worked. If a CDS employer submits the request, the CDS employer must notify their FMSA in writing, such as via 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 CDS employer submits the request and the payer has approved or denied the request, the payer must also notify the FMSA in writing, such as via email. If the FMSA sends the request on behalf of the CDS employer, the FMSA must notify the CDS employer of the approval or denial in writing, such as via email.

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

  • The program provider, FMSA, CDS employer or PSO was unable to manually enter and export an EVV visit during the visit maintenance time frame because of a state provided EVV system error 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 payer error or natural disaster.

When submitting a Visit Maintenance Unlock Request to create a manual visit because of a payer or EVV system error, the program provider, FMSA, CDS employer or PSO must provide evidence that demonstrates:

  • 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.

Correcting EVV visit transactions during an 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.

Program Provider, FMSA, CDS Employer or PSO Submission of Visit Maintenance Unlock Request

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

The program provider, FMSA or PSO 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
  • Bill Time In
  • Bill Time Out
  • Contract Number
  • Employee ID
  • HCPCS Code/Modifier
  • Member Medicaid ID
  • Modifier
  • NPI/API
  • Payer
  • Reason Code
  • Service Code
  • Service Group
  • Units
  • Visit Location
  • N/A – Create Manual Visit
  • 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
  • Bill Time In
  • Bill Time Out
  • Employee ID
  • HCPCS Code/Modifier
  • Member Medicaid ID
  • Modifiers
  • Payer
  • Reason Code
  • Service Code
  • Service Group
  • Units
  • Visit Location
  • N/A – Create Manual Visit
  • N/A – Export Only

If the visit transactions were recorded in a former EVV system and must be imported into the current EVV system, the program provider, FMSA, CDS employer or PSO must indicate this on the Visit Maintenance Unlock Request form. They must make sure visit transactions recorded in a former EVV system are in the Accepted status in the EVV Portal before including them in the request. CDS employers should work with their FMSA to make sure the visit transactions are in the Accepted status.

Emails with a completed Visit Maintenance Unlock Request must be sent securely and include a contact name, email address and phone number. Payers will deny Visit Maintenance Unlock Requests not sent securely because of a violation of the Health Insurance Portability and Accountability Act (HIPAA). Contact the payer for help with sending a secure email request.

The payer will deny the Visit Maintenance Unlock Request if it is missing required information or cannot be opened by the payer.

Visit Maintenance Unlock Request Job Aids are on the HHSC EVV website. The Job Aids provide step-by-step instructions to complete the Visit Maintenance Unlock Request form and submit the request.

The payer may request clarification of the Visit Maintenance Unlock Request. The program provider, FMSA, CDS employer or PSO must respond within 10 business days of the payer’s request for clarification, otherwise the Visit Maintenance Unlock Request will be denied. The program provider, FMSA, CDS employer or PSO must resubmit the Visit Maintenance Unlock Request with the requested clarification.

Payer Processing of Visit Maintenance Request

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

  • 10 business days
  • 30 business days if the request was submitted as supporting documentation for an MCO claims appeal

The Visit Maintenance Unlock Request is for visit transactions that were recorded in a former EVV system and must be imported from the Aggregator into the current EVV system. The payer must run the EVV Visit Maintenance report in the EVV Portal. An EVV Visit Maintenance Report Job Aid is in the EVV Training for MCOs section of the TMHP Learning Management System that includes step-by-step instructions to run the report. This is the payer’s responsibility and must be completed by the deadline for processing the Visit Maintenance Unlock Request.

Payer Request for Clarification

The payer may request clarification from the program provider, FMSA, CDS employer or PSO. The program provider, FMSA, CDS employer or PSO must provide the requested information within 10 business days of the payer’s request for clarification.

Once the program provider, FMSA, CDS employer or PSO responds, the payer must approve or deny the Visit Maintenance Unlock Request within 10 business days from the date the program provider, FMSA, CDS employer or PSO responds to the request for clarification.

If the program provider, FMSA, CDS employer or PSO does not respond by the deadline, the payer will deny the Visit Maintenance Unlock Request and the program provider, FMSA, CDS employer or PSO must submit a new request.

Payer Approval of Request

If the payer approves the Visit Maintenance Unlock Request, the payer will reply to the program provider’s, FMSA’s, CDS employer’s or PSO’s unlock request within 10 business days to confirm approval of the Visit Maintenance Unlock Request and copy the state provided EVV system vendor or EVV proprietary system vendor.

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

The state provided EVV system vendor or EVV proprietary system vendor must only allow changes to the items approved by the payer.

Payer Denial of Request

If the payer denies the request, the payer must notify the program provider, FMSA, CDS employer or PSO by email of the reason for the denial. The email notification must also include 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, modified or incorrect version of the Visit Maintenance Unlock Request form

Payer Incorrect, Incomplete or Retroactive Authorization Approvals

The payer must approve the Visit Maintenance Unlock Request when:

  • The payer included 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, CDS employer or PSO to resubmit an EVV visit transaction or EVV claim outside of the EVV visit maintenance time frame.
  • HHSC directs the payer to approve the Visit Maintenance Unlock Request.

State Provided EVV System Vendor and EVV Proprietary System Vendor Visit Transaction Unlock Process

Once the state provided EVV system vendor or EVV proprietary system vendor receives the approved Visit Maintenance Unlock Request from the payer, they must validate the information submitted and unlock the visit transaction within 10 business days of receipt of the approved Visit Maintenance Unlock Request.

If the Visit Maintenance Unlock Request is for visit transactions captured in a former EVV system, the state provided EVV system vendor or EVV proprietary system vendor must import the visit transactions into their system and make sure they are unlocked. The vendor then replies to the payer and the program provider, FMSA, CDS employer or PSO to indicate visit maintenance can be performed. This is included as part of the state provided EVV system vendor’s or EVV proprietary system vendor’s responsibilities and must be completed within the 10 business days allowed for processing the Visit Maintenance Unlock Request.

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

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

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

Program Provider, FMSA, CDS Employer or PSO Visit Maintenance

Once the visit transaction is unlocked, the program provider, FMSA, CDS employer or PSO has 20 business days to complete the visit maintenance. If necessary, the program provider, FMSA, CDS employer or PSO may request additional time to complete visit maintenance. The request for additional time must be made within 20 business days allowed for completing visit maintenance.

9070 Visit Maintenance and Billing EVV Claims

Revision 24-1; Effective Sept. 12, 2024

A program provider, FMSA and CDS employer must make sure all required data elements are correct and visit maintenance is complete before the program provider or FMSA submits 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).
  • Make sure the EVV Aggregator accepts the corrected EVV visit transaction.
  • Resubmit the EVV claim per the payer’s corrected claim process, such as 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.

9080 Last Visit Maintenance Date

Revision 25-1; Effective March 12, 2025

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
  • Texas EVV Service Provider ID
  • Contract number
  • Member Medicaid ID
  • Service group
  • Service code
  • HCPCS code
  • Modifier
  • Bill hours
  • Units

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

9090 Visit Maintenance Reduction Features

Revision 24-1; Effective Sept. 12, 2024

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 system 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 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 data 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 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 make sure the member’s plan of care is followed. Although visit maintenance reduction features are available and add flexibility, the member’s needs 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.