To provide information to the CDS employer on requirements for using an Electronic Visit Verification (EVV) system to electronically verify that the CDS employee delivers the required Medicaid services and documents the date and time service delivery begins and ends.
The CDS employer may elect to perform EVV visit maintenance, as needed, to correct visit information and to approve time worked by their employees. The CDS employer may elect to have their Financial Management Services Agency (FMSA) perform some or all EVV system functions on their behalf.
When to Prepare
The FMSA and CDS employer must complete this form at the time of EVV implementation for a program or service delivered through the CDS option, upon enrollment in the CDS option and any time the CDS employer requests a change in designation of EVV responsibilities.
The FMSA explains the responsibilities of the CDS employer and FMSA for using the EVV system. The CDS employer will choose the appropriate option:
- Who completes visit maintenance: the CDS employer or the FMSA.
- Who approves the time worked by the employee:
- the CDS employer approves time worked in the EVV system; or
- the CDS employer elects to have the FMSA confirm the time worked in the EVV system based on approval by the CDS employer.
The FMSA must process and select the appropriate option(s) in the EVV system within five business days of receiving a completed form, unless otherwise directed by HHSC.
If a completed form is not received by the FMSA, the FMSA will not make a selection in the EVV system and will note this in the CDS employer’s file.
Number of Copies
One copy for the FMSA and one copy for the CDS employer.
The FMSA gives a copy of Form 1722 to the CDS employer to complete.
The CDS employer keeps a copy and the FMSA keeps a copy. The CDS employer and FMSA must keep the form while it is in effect, or until resolution of all outstanding litigation, claims and audits.
1. Name of the Person Receiving Services — Enter the name of the person receiving services.
Note: Managed care programs and HHSC EVV policy may refer to the person receiving services as the “Member.”
2. CDS Employer’s Name (if different from the person receiving services) — Enter the name of the person receiving services, who is age 18 or over and does not have a legal guardian, or their legally authorized representative.
3. Identification Number — This is for FMSA use only and allows the FMSA to enter a unique tracking number for each person receiving services.
4. Relation to Person Receiving Services — If the CDS employer is not the one receiving services, define the relationship between CDS employer and recipient.
EVV Vendor Name — Enter the name of the EVV vendor, if applicable. If the FMSA has elected to use their own proprietary system, then this field will remain blank.
EVV System Name — Enter the name of the EVV system.
Note: The EVV system name may be an EVV vendor system from the state vendor pool or the FMSA’s EVV proprietary system.
EVV System Contact Information — Enter the contact information of the EVV system.
Selection for EVV System Access and Visit Maintenance Responsibilities — The CDS employer places a mark in the box next to the option they select. The CDS employer may only select one option. If the CDS employer decides to change to a different option at any time, they must complete a new Form 1722.
Option 1: The CDS employer agrees to perform all visit maintenance and approve their employee’s time worked in the EVV system.
Option 2: The CDS employer elects to have their FMSA complete all visit maintenance on their behalf; however, the CDS employer will approve their employee’s time worked in the EVV system.
Option 3: The CDS employer elects to have their FMSA complete all visit maintenance on their behalf and confirm the employee’s time worked in the EVV system based on approval documentation from the CDS employer.
I agree that the selections made on this form will become effective on — Enter the date that the changes will take effect.
Signature ─ CDS Employer and Date — The CDS employer signs and dates the form, indicating the FMSA has reviewed the information on the form with the CDS employer.
Signature ─ FMSA Representative and Date — The FMSA signs and dates the form, indicating they have explained EVV and the CDS employer understands the form.